2012 Texas Chapter

Scientific Meeting Jointly Sponsored by Scott & White

November 3–4, 2012

Omni Hotel

Fort Worth, TX

Timely Topics in Internal Medicine 2012

Register online now!

Fostering Excellence in Internal Medicine

American College of Physicians

Dear Colleague, The Texas Chapter of the American College ofPhysicians—your partner and champion of internalmedicine—is coming to Fort Worth in November! Weinvite you, your friends, and your colleagues from allacross our great state to join us for this exceptional meeting. Scientific updates, procedural workshops, andthe latest news and resources from the College will all bea part of the program to provide you with comprehensivetools for your practice. The 2012 annual meeting isplanned for Saturday and Sunday, November 3 and 4, at the beautiful Omni Hotel in Fort Worth. Pre-course sessions will provide the opportunity to obtaincredit toward American Board of Internal Medicine(ABIM) Maintenance of Certification. The ABIM’sSelf-Evaluation Process Modules on Office-BasedInternal Medicine and Hospital-Based Internal Medicinewill be offered on Friday, November 2, from 1:00 to5:30 p.m. Seating will be limited to 30 to enable aninteractive learning format and audience response system. In addition to earning CME credits, you will enjoy theopportunity to:• Fulfill the one-hour ethics requirement for renewalof your medical license.

• Discuss local and national issues affecting the practice of internal medicine.

• Greet old friends and meet new ones.• Bring your family and enjoy all that Fort Worth has to offer.

Steven Weinberger, MD, FACP, Executive Vice Presidentand Chief Executive Officer of the American Collegeof Physicians, will attend our meeting to talk aboutmedicine’s issues from the national perspective. Moreimportant, he wants to hear from you and understandthe unique viewpoint of our Texas Chapter members.The annual meeting provides an Administrator oppor-tunity to make your voice heard by ACP leadership.Visit the annual meeting Web page at www.txacp.orgto register, or complete the form at the back of thisbrochure and mail or fax it today.Of course, the Texas ACP meeting is not limited to ACPmembers. Nonmembers are welcome to join us for thisimportant clinical update and to learn about the benefitsof membership at the same time. We encourage you toshare this information with your colleagues.Sincerely,Clark R. Gregg, MD, FACPGovernor, ACP Texas Northern Region

Robert E. Jackson, MD, FACPGovernor, ACP Texas Southern Region

Sue S. Bornstein, MD, FACPGovernor-elect, ACP Texas Northern Region

Felicia Austin, MD, FACPPresident, ACP Texas Chapter

GOVERNOR’S LETTER

Texas ChapterMeeting Highlights:• Associates’ and medical students’ clinical vignette and poster competitions

• Awards luncheon to recognizeour Young Physician Leader ofthe Year, Advocate of the Year,Texas Chapter Laureates and Volunteerism Award recipients

• Exhibit hall with the latest inproducts and services for the medical community

• ABIM SEP modules on Office-Based Internal Medicine and Hospital-Based InternalMedicine for recertification

Scott & White Hospital

designates this live activity

for a maximum of 16 AMA

PRA Category 1 Credits TM.

Physicians should claim

only credit commensurate

with the extent of their

participation in the activity.

The 16 AMA PRA Category 1

CreditsTM includes 4 hours

total for the optional ABIM

Recertification SEP modules

and 2 hours for the optional

breakfasts.

SCIENTIFIC PROGRAM AND

SPECIAL EVENTS

Friday, November 2, 2012 1:00– ABIM Recertification SEP Module:3:00 p.m. Office-Based Internal Medicine

(Advance registration required.Additional registration feeapplies. Limited to 30 participants.)

Stephen J. Sibbitt, MD, FACP

Curtis R. Mirkes, DO, FACP

3:30–5:30 ABIM Recertification SEP Module:Hospital-Based Internal Medicine(Advance registration required.Additional registration feeapplies. Limited to 30 participants.)

Stephen J. Sibbitt, MD, FACP

Curtis R. Mirkes, DO, FACP

Saturday, November 3, 20127:00 a.m. Registration

Continental breakfast withthe exhibitors

7:00 Women in Medicine NetworkingBreakfast

Moderator:Sue S. Bornstein, MD, FACP

Temple S. Howell-Stampley,MD, FACP

7:00 Advancement to FellowshipBreakfast

Moderators:Clark R. Gregg, MD, FACP

Robert E. Jackson, MD, FACP

Plenary SessionModerator: Daniel M. Goodenberger,

MD, MACP

8:00 WelcomeClark R. Gregg, MD, FACP

8:00 Adult Congenital Heart Disease:What the Primary Care ProviderNeeds to KnowBeth Brickner, MD

8:45 To Test or Not to Test: Genetic Testingin AdultsDimple Sureka, MD

9:30 Stump the ProfessorMark Feldman, MD, MACP

10:15 BreakVisit the exhibits and theCollege display

10:40– Associates’ Clinical Vignette11:50 a.m. Competition

(order to be determined)

Moderator:Suma Pokala, MD, FACP

Bowel-Associated Dermatitis-ArthritisSyndrome in a Nonsurgical PatientElan Gada, MD

Aortic Valve Associated PrimaryCardiogenic LymphomaFahmi Farah, MD

A Spongy HeartChristopher W. Larson, DO

Polycythemia Vera-cesKaushal Patel, MD

Fishing for a DiagnosisArati Rani Chand, MD

12:00 Texas Chapter Annual BusinessMeeting and Awards Luncheon

Plenary SessionModerator: Clark R. Gregg, MD, FACP

1:30 p.m. On Being a Doctor: The New Doctor:The Impact of Generational Shiftsand a Changing Medical EducationalEnvironment.Winner of the Associate/Medical Student writingcompetition to be announced

1:45 GERD/Barrett’s Esophagus/Esophageal CancerStuart Spechler, MD

2:30 Office Evaluation of CommonOrthopedic ProblemsStephen Brotherton, MD

3:15 BreakVisit the exhibits andCollege display

3:40 ACP in the Era of Health Care Reform Steven Weinberger, MD, FACP

4:25 Sarcoidosis: Chasing an ElusiveDiseaseSteven Weinberger, MD, FACP

5:10 Adjourn

5:30– Cocktail Reception and Awards 7:00 p.m. Presentations

Sunday, November 4, 20127:30 a.m. Registration

Continental breakfast withthe exhibitors

7:30–8:30 Advocacy Update

Moderators:Jack Myers, MD, FACP

Alejandro Moreno, MD,MPH, JD, FACP

7:30–8:30 Council of Young PhysiciansBreakfast

Moderators:Pete Yunyongying, MD, FACP

Amy LaViolette, MD, FACP

Plenary SessionModerator: Daniel M. Goodenberger,

MD, MACP

8:30 a.m. WelcomeClark R. Gregg, MD, FACP

8:30 a.m. Gout: Managing an Ancient DiseaseWith Conventional and Newer AgentsSalahuddin Kazi, MD, FACP

9:15 A Window to the Body: OcularManifestations of Systemic DiseasesRafael Ufret-Vincenty, MD

10:00 MEN for the InternistHans K. Ghayee, DO, ACPMember

10:45 BreakVisit the exhibits and theCollege display

11:10 Ethics and Law at the End of LifeElizabeth Polanco, MD

12:10 p.m. Adjourn

Optional Pre-Course LearningSessions

Friday, November 2, 20121:00– ABIM Self-Evaluation Process3:00 p.m. Module: Office-Based Internal

MedicineStephen J. Sibbitt, MD, FACP

Curtis R. Mirkes, DO, FACP

3:30–5:30 ABIM Self-Evaluation ProcessModule: Hospital-Based InternalMedicineStephen J. Sibbitt, MD, FACP

Curtis R. Mirkes, DO, FACP

Each module is limited to 30 partici-pants. Advance registration and additional registration fee required. See registration form.

Learn in an interactive environment as clinical experts lead discussion of 20case-based questions from AmericanBoard of Internal Medicine’s Self-Evaluation Process (SEP) Modules onOffice Based Internal Medicine andHospital Based Internal Medicine.The primary purpose of the session isto facilitate completion of SEP mod-ules for Maintenance of Certification(MOC) credit. After ordering themodules from ABIM, participants will submit answers at the completionof the session for credit toward theMOC program.

SCIENTIFIC PROGRAM AND

SPECIAL EVENTS

MEETING INFORMATION

FACULTYSue S. Bornstein, MD, FACP,Past-President, Governor-elect, ACPTexas Northern Region, ACP TexasChapter, Executive Director, TexasMedical Home Initiative, Dallas

Beth Brickner, MD, Professor ofInternal Medicine, Director of theAdult Congenital Heart DiseaseClinic, University of TexasSouthwestern Medical Center, Dallas

Stephen Brotherton, MD, Bone andJoint Clinic, Texas Health Care FortWorth; Adjunct/Clinical Faculty,Texas Christian University and Fort Worth Affiliated HospitalsOrthopedic Residency Program;President-Elect of the Texas MedicalAssociation, Fort Worth

Arati Rani Chand, MD, ACPAssociate,Winner, NorthwestRegional Associates’ Clinical VignetteCompetition, Texas Tech UniversityHealth Sciences Center Amarillo,Amarillo

Elan Gada, MD, ACP Associate,Winner, Northeast Regional Associates’Clinical Vignette Competition,University of Texas SouthwesternMedical Center, Dallas

Hans K. Ghayee, DO,AssistantProfessor of Medicine, University of Texas Southwestern MedicalCenter, Dallas

Fahmi Farah, MD, ACP Associate,Winner, Southwest Regional Associates’Clinical Vignette Competition, TexasA&M Health Science Center at Scott&White, Temple

Mark Feldman, MD, MACP,William Tschumy Chairman of theDepartment of Internal Medicine,Medical Director for Research,Presbyterian Hospital of Dallas;Clinical Professor of InternalMedicine, University of TexasSouthwestern Medical Center, Dallas

Daniel M. Goodenberger, MD,MACP,Chief, Medical Service,Veterans Affairs North Texas Health Care System, Professor andVice-Chair, Internal Medicine,University of Texas SouthwesternMedical Center, Dallas

Clark R. Gregg, MD, FACP,Governor, ACP Texas NorthernRegion; Chief of Staff, VeteransAffairs North Texas Health CareSystem; Professor of Medicine,Department of Internal Medicine,Division of Infectious Diseases,University of Texas SouthwesternMedical Center at Dallas, Fort Worth

Robert Jackson, MD, FACP,Governor, ACP Texas SouthernRegion; Clinical Professor ofMedicine, Weill Cornell MedicalCollege, Houston

Salahuddin Kazi, MD, FACP,ChiefHealth Informatics Officer, VeteransAffairs North Texas Health CareSystem; Associate Professor of InternalMedicine, Division of Rheumatology,University of Texas SouthwesternMedical Center, Dallas

Christopher W. Larson, DO, ACPAssociate,Winner, Far NorthwestRegional Associates’ Clinical VignetteCompetition, William BeaumontArmy Medical Center, El Paso

Amy LaViolette, MD, MPH, FACP,Assistant Professor, University ofTexas Southwestern Seton Family ofHospitals, Austin

Curtis R. Mirkes, DO, FACP,Assistant Professor of Medicine,Associate Residency ProgramDirector, Department of InternalMedicine, Scott & White MemorialHospital, Texas A&M UniversityHealth Science Center College ofMedicine, Temple

Alejandro Moreno, MD, MPH, JD,FACP, FCLM,Associate Director,Internal Medicine Residency Program,University of Texas SouthwesternResidency Programs at Seton Familyof Hospitals, Austin

John D. ‘Jack’ Myers, MD, FACP,Associate Professor of Medicine, Vice Chair for Educational Affairs,Director, Division of General InternalMedicine, Scott & White Hospitaland Clinic, Temple

Kaushal Patel, MD, ACP Associate,Winner, Southeast Regional Associates’Clinical Vignette Competition,Baylor College of Medicine, Houston

Suma Pokala, MD, FACP,AssistantProfessor of Medicine, Department of Internal Medicine, Central TexasVeterans Health Care System, TexasA&M University System College ofMedicine, Temple

Elizabeth Polanco, MD,VeteransAffairs North Texas Health CareSystem, Associate Professor, InternalMedicine, University of TexasSouthwestern Medical Center, Dallas

Stephen J. Sibbitt, MD, FACP,Associate Professor of Medicine,Department of Internal Medicine,Chief Medical Officer, Scott &WhiteMemorial Hospital, Texas A&MUniversity Health Science CenterCollege of Medicine, Temple

Stuart Spechler, MD,Chief,Gastroenterology Section, VeteransAffairs North Texas Health CareSystem, Professor of Medicine, PattersonChair in Gastroenterology, Universityof Texas Southwestern MedicalCenter, Dallas

Temple Howell-Stampley, MD, FACP,Associate Professor of Internal Medicine,University of Texas SouthwesternMedical Center, Dallas

Dimple Sureka, MD,ClinicalAssistant Professor of Genetics, EugeneMcDermott Center for Human Growth& Development, University of TexasSouthwestern Medical Center, Dallas

Rafael Ufret-Vincenty, MD,Assistant Professor, Department ofOphthalmology, University of TexasSouthwestern Medical Center, Dallas

Steven Weinberger, MD, FACP,Executive Vice President and CEO,American College of Physicians;Adjunct Professor of Medicine,University of Pennsylvania School of Medicine, Philadelphia, PA

Pete Yunyongying, MD, FACP,Veterans Affairs North Texas HealthCare System, Instructor, InternalMedicine, University of TexasSouthwestern Medical Center, Dallas

Special Events for MedicalStudents and Associates

Friday4:00– Medical Students’ and Associates’6:00 p.m. Poster Set-up

Saturday7:00– Medical Students’ and Associates’ 9:00 a.m. Poster Set-up

9:00–10:30 Medical Students’ Clinical VignetteCompetition

Moderator: Gene Stokes,MD, FACP

10:35–11:50 Associates’ Clinical VignettePresentations and Competition(during Plenary Session)

Moderator: Suma Pokala,MD, FACP

1:30 p.m. On Being a Doctor: The NewDoctor: The Impact of GenerationalShifts and a Changing MedicalEducational Environment. The winning author of the On Being aDoctor writing competition forMedical Student and Associatemembers will give a 10-minuteoral presentation during thePlenary Session.

2:00–4:30 Medical Students’ and Associates’Poster Exhibition and Competition

Moderators: Karen E.Szauter, MD, FACP, andSuma Pokala, MD, FACP

5:30–7:00 Cocktail Reception

Winners of the poster andclinical vignette competi-tions will be announced.

Sunday11:30 a.m.– Associates’ Luncheon and Doctor’s2:00 p.m. DilemmaTM Competition

Moderators: George E.Crawford, MD, FACP, andSuma Pokala, MD, FACP

MEETING INFORMATION

MEETING INFORMATION

Medical Students’ andAssociates’ ActivitiesMedical students and residents areinvited to participate in all annualmeeting events, especially those activities designed specifically fortheir interests. Although registrationis free, students and residents mustregister for the meeting in advance.

Winners of the five regional Associates’clinical vignette competitions willpresent their cases in the statewidecompetition during the plenary sessionon Saturday morning. The winner willadvance to ACP’s national competitionin San Francisco in April 2013.

Medical students will present clinicalvignettes in a competition, with thewinners to receive cash prizes. Thestudent who achieves first place willbe eligible for the national competitionat the 2013 ACP annual meeting.

First-, and second-place winners willbe named in the Medical Students’and Associates’ poster competitions.

Students and Associates are alsoencouraged to submit original prose or poetry dedicated to the theme The New Doctor: The Impact ofGenerational Shifts and a ChangingMedical Educational Environmentfor the On Being a Doctor writingcompetition. The winning author ofthe On Being a Doctor competitionwill share his or her composition in a 10-minute oral presentation duringthe Plenary Session on Saturday.

The thirteenth annual Doctors’DilemmaTM statewide competition will begin with a luncheon on Sunday.All Internal Medicine residency pro-grams in Texas are invited to registertheir team in advance and come joinin the fun.

Visit the TXACP Web site atwww.txacp.org for complete details on all of the student and residentevents, or call the Chapter BusinessOffice at 512-370-1508.

AwardsThe annual business meeting and awardsluncheon on Saturday, November 3,will include recognition of the recipi-ents of the Texas Chapter LaureatesAward, Texas Chapter Volunteerismand Community Service Award,Advocate of the Year Award, and theYoung Physician Leadership Award.

Evergreen Award The John Tooker Evergreen Programwas created in 1993 by the College to recognize and reward outstandingchapter efforts. The John TookerEvergreen Program provides visibilityto those chapters that have been successful in implementing programsthat increase member communicationand involvement.

Each year all chapters are invited tonominate their own programs and toprovide details on the goals of the program, how it was implemented,and what the results were. The ChaptersSubcommittee has the difficult task of selecting a small group of winningchapters, which are recognizednationally and locally for theirachievements.

We are excited to announce the 2012John Tooker Evergreen Award will be presented to our chapter for theTexas Medical Home Initiative.

Chapter Excellence AwardWinner We are proud to announce that theTexas Chapter is the recipient of a2011 Chapter Excellence Award. TheChapter Excellence Award recognizesthose chapters that excel in reachingthe highest standards for managing achapter, such as communicating tomembers, hosting medical student andassociate activities, and recruiting andadvancing members.

MEETING INFORMATION

Acknowledgments(as of July 2012)

This program is supported, in part, byunrestricted grants from:

Gold Level

• Texas Health Harris MethodistFoundation

CME Development andAccreditationThis activity has been planned andimplemented in accordance with theEssential Areas and Policies of theAccreditation Council for ContinuingMedical Education (ACCME) throughthe joint sponsorship of Scott & Whiteand the Texas Chapter of the ACP.Scott & White is accredited by theACCME to provide continuing medical education for physicians.

Scott & White designates this liveactivity for a maximum of 16 AMAPRA Category 1 CreditsTM.

Physicians should claim only creditcommensurate with the extent oftheir participation in the activity.The 16 AMA PRA Category 1CreditsTM includes 4 hours total forthe optional ABIM RecertificationSEP modules and 2 hours for theoptional breakfasts.

The ABIM Recertification SEP modules on Friday, November 2, from1:00–3:00 p.m. and 3:30–5:30 p.m.,are each approved for an additional 2 AMA PRA Category 1 CreditsTM

for a total of 4 AMA PRA Category 1 CreditsTM.

The following session is approved forethics credit: “Ethics and law at theend of life,” Plenary Session, Sunday,November 4, 11:10 a.m. (1 hour).

The need for this program was identified from the results of a surveyof evaluations and suggestions frompast participants, along with inputfrom the chapter’s Education Committee.The program will consist of lectures,supplemented with audiovisual presentations.

A course evaluation form will provideparticipants the opportunity to revieweach session and speaker and suggestfuture topics.

Who Should Attend• General internists

• Subspecialty internists

• Family physicians

• Fellows in subspecialty training

• Allied health practitioners

• Residents

• Medical students interested ininternal medicine

SyllabusThe syllabus will be available onlinebefore the meeting so attendees canprint out the syllabus in advance.More information will be sent to eachattendee after they register regardingthe online passphrase and password.Make sure to include a primary e-mailaddress on the registration form so thatthis information can be distributed.

Learning ObjectivesAt the conclusion of this activity, the participant should be able to:

• Analyze the approach to the diagnosis and counseling of thepatient with a heritable disease

• Review the diagnostic approach tothe adult patient with suspectedcongenital heart disease

• Outline the presentation and evaluation of patients and familieswith multiple endocrine neoplasia

• Describe recent developments inpalliative care

• Identify the relationship betweenGERD, Barrett’s esophagus, andesophageal cancer, with greaterunderstanding of prevention andtreatment

• Review the approach to the diagnosisand treatment of sarcoidosis

• Update diagnostic and therapeuticskills for common outpatient orthopedic problems

• Discuss the latest treatment of gout

• Recognize ocular clues to the diagnosis of important systemic diseases

Hotel AccommodationsAs breathtaking as any West Texassunset, the Omni Fort Worth Hoteloffers a taste of Texas hospitality.Conveniently located at the heart ofFort Worth’s exciting downtown area,the hotel is within walking distance fromthe city’s cultural centers, restaurants,and nightlife. Retreat to your luxuriousguest room accommodations for arestful night’s sleep after you exploreFort Worth.

The host hotel is more than just aconvenient place to stay during theannual meeting. TXACP contractswith a host hotel each year, promisinga minimum number of sleeping roomsto the hotel. In return, the hotel offersTXACP complimentary or reducedmeeting room rental and other servicesthat make the chapter meeting a success.By booking your room at the host hotel,you will help to keep registration costsand member dues low.

A special block of rooms has beenreserved at the:

Omni Fort Worth1300 Houston StreetFort Worth, TX 76102

To make reservations, dial 800-THE-OMNI or 800-843-6664and mention that you are attendingthe TXACP meeting to receive thegroup rate.

Rates:Single/Double occupancy: $174

This rate is available to registrantsuntil the room block is full orThursday, October 11. The specialgroup rate is available one day beforeand one day after the meeting, basedupon availability.

Parking Valet parking is available forovernight guests at $22 per night.Overnight self-parking is $14.

Airport ShuttleThe Omni Fort Worth does not offercomplimentary shuttle service fromthe airport, but the hotel concierge is available at 800-258-3826 to assistyou in making your arrangements for a shuttle or limousine services.

Driving DirectionsVisit www.omnihotels.com/FindAHotel/FortWorth/MapAndDirections.aspx, or call the hotel concierge for assistance at 800-258-3826.

MEETING INFORMATION

To register online for the meeting, go to www.txacp.org, then select “AnnualMeeting.”

To register via fax or mail, complete the attached registration form and return itwith your check made payable to Scott & White or with credit card information to:

Scott & WhiteDepartment of Continuing Medical Education2401 South 31st Street, MS 26–A229Temple, TX 76508Phone: 800-724-7280 or 254-724-7609FAX: 254-724-1753

*There is an additional $20 fee for registering onsite at the meeting. Save moneyby registering early.

*Registrations received prior to October 19 will receive confirmation in the mailor by e-mail.

*Refunds (minus a $50 administration fee) will be provided to registrants whocancel their registration in writing prior to October 19. No refunds will be provided for cancellations received after October 19.

Registration fee includes all scientific plenary sessions and materials, Saturdaycocktail reception, continental breakfasts and refreshment breaks, luncheon onSaturday, and CME certificate. An additional registration fee is required for theABIM SEP Module pre-course.

To access online meeting information or to print another registration form for acolleague, go to www.txacp.org, Annual Meeting.

For questions about the meeting, contact:

Texas Chapter Business OfficePhone: 512-370-1508E-mail: gena.girardeau@texmed.org

For information on College-related issues, contact your Governor:

Clark R. Gregg, MD, FACPTexas Northern RegionPhone: 214-857-1150E-mail: greggacp@sbcglobal.net

Robert E. Jackson, MD, FACPTexas Southern RegionPhone: 713-791-9305E-mail: rejackson@tmhs.org

HOW TO REGISTER

Obtain credit toward your American Board of Internal Medicine Maintenance of Certification (MOC) on Friday, November 2, from 1:00–5:30 p.m., in FortWorth at the TXACP annual chapter meeting. TXACP faculty will present twoABIM Self Evaluation Process Modules, 2012 Updates in Office-Based InternalMedicine and Hospital-Based Internal Medicine, as pre-courses to the annualchapter meeting. Each SEP module contains 20 to 25 multiple-choice questionsto be completed through group discussion and with the help of an automatedaudience response system.

Upon completion of the session, attendees will be able to submit their answers to ABIM for scoring and points toward the self-evaluation of knowledge requirement associated with the MOC Program.

Advance registration is required and will be limited to 30 participants.

The fee for each Learning Session is $75 for ACP members and $125 for non-members. The fee covers the costs for the educational support and refreshmentsprovided at the session and should be paid directly to TXACP.

To participate in this session:

1) Register in advance by completing the TXACP Annual Meeting registrationform in the brochure or online, select the ABIM SEP Modules under “SpecialEvents,” and submit registration fee to TXACP.

2) If you are enrolled in the ABIM MOC process you may order your SEP modulesfrom ABIM at www.abim.org/online/ or call 800-441-2246 prior to the sessionto expedite receiving credit for the SEP modules from ABIM.

3) You may bring your modules with you to the Learning Session; note that wewill provide all course registrants with a printed version of the SEP modulesonsite.

4) Submit your answers to ABIM for MOC credit after the Learning Session viathe ABIM Web site (for immediate results).

For more information about ABIM’s MOC program, visit www.abim.org/moc/ or call 800-441-2246.

Program CommitteeClark R. Gregg, MD, FACP, Governor, ACP Texas Northern Region, Fort Worth, TX

Daniel M. Goodenberger, MD, MACP, Local Program Committee Chair, Dallas, TX

Special ConsiderationsWe do try to control the temperature in the meeting room, but for your comfort,please bring a jacket.

HOW TO REGISTER FOR

ABIM SEP

American College of Physicians RM1339Texas Chapter Scientific Meeting November 3–4, 2012

This form may be photocopied.

ACP # (found on mailing label)

Name ❏MD ❏DO

Address

City/State/Zip

Daytime Phone

Fax

E-mail

❏ Please check here to indicate a permanent change to your preferred address forall College mailings.

❏ Yes, I do wish to receive information from the meeting exhibitors.

Registration Fees:Check one category that best applies. Registration fee includes continentalbreakfast, lunch, all scientific sessions and materials, and a CME certificate.

ACP Categories:❏Master ❏ Fellow ❏Member ................................................................... $195❏Associate (Resident Member)............................................................... No Fee❏Medical Student Member ..................................................................... No Fee❏Affiliate Member (Allied Health Professional) ........................................ $195

Nonmember Categories:❏Nonmember Physician ............................................................................. $245❏Nonmember Resident ........................................................................... No Fee❏Nonmember Medical Student .............................................................. No Fee❏Nonmember Allied Health Professional .................................................. $245

Special Events and Fees: ❏ABIM SEP Module IM – Office Based 2012, 1:00 p.m., November 2 (Member rate) ....................................................................... $75

❏ABIM SEP Module IM – Office Based 2012, 1:00 p.m., November 2 (Nonmember rate)............................................................... $125

❏ABIM SEP Module IM – Hospital Based 2012, 3:30 p.m., November 2 (Member rate)........................................................................ $75

❏ABIM SEP Module IM – Hospital Based 2012, 3:30 p.m., November 2 (Nonmember rate)............................................................... $125

❏Advancement to Fellowship Breakfast, 7 a.m., November 3 ................. No fee❏Women in Medicine Breakfast, 7 a.m., November 3 ............................. No fee❏Council of Young Physicians Breakfast, 7:30 a.m., November 4 .......... No Fee❏Advocacy Update Breakfast, 7:30 a.m., November 4............................ No Fee❏Guest Luncheon Ticket, Noon, November 3 ............................................ $ 35

GRAND TOTAL $ ______________

REGISTRATION FORM CMB

✁Cut H

ere

Please bill my:

Account Number: __________________________________________________

Name on Card: ___________________________________ Exp. Date: ________

Signature: _________________________________________________________

Total $ ______________

With credit card payment, register online at www.txacp.org, or fax completedform to 254-724-1753. By mail, make your check payable to Scott & White and send to:

Scott & WhiteDepartment of Continuing Medical Education2401 South 31st Street, MS 26–A229Temple, TX 76508

Questions about registering? Please call Scott & White at 800-724-7280 or 254-724-7609

Special Considerations:� ❏Check if you are disabled and require assistance. Attach a written description

of needs and submit with your registration or contact Texas Chapter of ACPby October 19.

� ❏Check if you require a vegetarian diet.

REGISTRATION FORM CMB

MM / YY

NOTES

NOTES

190 N. Independence Mall West

Philadelphia, PA 19106-1572

Jointly Sponsored by Scott & White

November 3–4, 2012

Omni Hotel

Fort Worth, TX

2012 Texas Chapter of the

ACP Scientific Meeting

CHS2001

NO

NP

RO

FIT

OR

G.

U.S

. PO

STA

GE

PAID

AC

P