Follow the steps to complete the certification form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Part 1, where you will provide information about the physician representative and the organization. Fill in the physician representative's name, title, email address, preferred phone number, and Medical Education number if available. Indicate if the physician is an AMA member and a member of the AMA House of Delegates.
3. Next, enter the health care organization's name, the number of physicians in the organization, and the name and title of the lead physician executive, if different from the representative. Provide email and mailing addresses accurately.
4. Proceed to Part 2, where you will check the characteristics that apply to your organization. Ensure that your organization meets the requirements based on whether it is an associate or affiliate member.
5. In Part 3, you will certify that the physician representative is a member of your organization and that the checked criteria reflect your organization's characteristics. Electronically sign the certification by checking the box and typing your name.
6. After completing the form, review all the information you have provided to ensure accuracy. Once you are satisfied, save the changes, then download or print the form as needed.
7. Finally, submit your completed certification form either by emailing it to carrie.waller@ama-assn.org or faxing it to (312) 464-2450.

Complete your American Medical Association IPPS Representative Certification Form online today!