Medical Acupuncture for Physicians AC74 Application

Medical Acupuncture for Physicians
Fall 2023 – Spring 2024
Application

Tempe Mission Palms Conference Center, Tempe, AZ
Module One: November 9-12, 2023
Module Two: February 1-4, 2024
Module Three: May 30 – June 2, 20234

The final day of each in-person module ends at noon local time.

There will also be additional shorter meetings delivered via Zoom in between the primary units, as well as 6-8 hours per week of home study video and reading assignments.

In addition to completing this form, the following documents are required for your application to be considered. You must submit them via email to mafp@hmieducation.com:

Résumé / CV
Photocopy or scan of your current medical license
Statement of plans on your interest in acupuncture and how you will incorporate it into your practice. (For military applicants, please include in your statement confirmation of your base command’s endorsement of your training and an acupuncture-friendly clinical setting.)

The fields indicated with an asterisk (*) are required.

Name And Professional Information

First Name*

Middle Initial

Preferred Name*

Last Name*

Pronouns*

Date of Birth*

Degree*

State Issuing Medical License*

Medical License Number*

Specialty 1*

Specialty 2

Contact Information

Primary Email*

Military personnel and government employees must list a non-work email address for their primary email.

Work Email

Home Address:

Street*

Street address only, no P.O. boxes.

City*

State*

Zip*

Personal Phone*

Please use the format 555-555-5555 for US phone numbers.

Work Phone

Please use the format 555-555-5555 for US phone numbers.

Military Personnel & Government Employee Applicants Only

Service Branch

Military Rank

Date of end of obligated service

Tuition*

300-Hour CME course: $12,650 by credit card, $12,350 by checkFull-time Resident or Fellow rate (self-pay): $10,550 by credit card, $10,250 by checkResident/Fellow rate only available if applicant is self-paying. Tuition paid by Residency/Fellowship Program is not eligible for discounted rate.

Indicate method of payment:*

CheckPreferred - Payable to Helms Medical Institute, 2520 Milvia Street, Berkeley, CA 94704Credit Card - onlinePay online at https://mkt.com/hmiCredit Card - by phoneCall 510-649-8488 between 10am and 3pm Pacific Time or fax to 510-649-86923rd Party PaymentSpecify:

All training activities will take place at the Tempe Mission Palms Hotel & Conference Center, Tempe, Arizona. You are requested to lodge at the hotel where a group rate has been arranged (average of $225 per night + $12.95 nightly destination fee + tax). A conference day use fee of $89 per day is required of participants who choose to stay elsewhere or room with another course participant.
All participants are strongly encouraged be fully vaccinated against COVID-19 to participate at in-person activities. Additional health and safety precautions may be implemented at the in-person teaching activities and these measures must be followed by all attendees.
For additional information about this course, call 510-649-8488 or e-mail mafp@hmieducation.com. Once you have submitted this online application you will receive a confirmation email.