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TENNESSEE ACADEMY OF FAMILY PHYSICIANS

63rd AnnuAl Assembly & scientific ProgrAm

Convention Center Gatlinburg, Tennessee October 25-28, 2011

CME ACCREDITATION

THIS LIVE ACTIVITY HAS BEEN REVIEWED AND IS ACCEPTABLE FOR UP TO 14.25*** PRESCRIBED CREDITS BY THE AMERICAN ACADEMY OF FAMILY PHYSICIANS.

(Physicians should claim only the credit commensurate with the extent of their participation in this activity.)

***Additionally, the following lectures have been approved & accredited to the Primary Care Education Consortium (PCEC): Wednesday, 10/26, 8:30 a.m. to 9:30 a.m. ­ "Asthma" - Tim Vega, M.D.

***Overall CME approval for the Tennessee AFP Annual Meeting including Doctor Tim Vega's `Asthma' presentation accredited to the Primary Care Education Consortium (PCEC) is 15.25 Prescribed credits (14.25 TNAFP/1 PCEC).

AAFP Prescribed credit is accepted by the American Medical Association as equivalent to AMA PRA Category I Credit toward the AMA Physicians Recognition Award. (When applying for the AMA PRA, Prescribed credit earned must be reported as Prescribed, not as Category I.)

OBJECTIVES:

Attendees will receive current information on a wide range of medical topics pertinent to the practice of Family Medicine. Topics were chosen for the 2011 Scientific Assembly from recommendations submitted on evaluation forms completed by 2010 and 2009 Scientific Assembly attendees. Objectives for each individual presentation will be included in the registration notebooks with speaker handouts given to each attendee on-site at the meeting.

2011 ANNUAL SCIENTIFIC ASSEMBLY PROGRAM COMMITTEE:

Beth Anne Fox, M.D., Kingsport (Chair) Wes Dean, M.D., Powell Chris Gafford, M.D., Fayetteville Kellie Wallace Wilding, M.D., Jackson Gregg Mitchell, M.D., Jackson Kim Howerton, M.D., Jackson

SPECIAL ­ Thursday: Halloween Trick-or-Treat:

On Thursday afternoon from 3:30 p.m. to 4:30 p.m. children of all attendees and exhibitors are cordially invited to trick-or-treat at the exhibit booths in the TNAFP Exhibit Hall. Children and all adults (exhibitors and attendees) as well, are invited, and encouraged, to dress in their favorite costume. There will be an Exhibitor's Costume Contest and Exhibit Booth Decorations/Group Costume Contest with winners being announced and prizes awarded between 3:30 and 4:30 p.m. We hope that all of you will participate in this fun family time!

A Special `Thank You' to our Supporters and Sponsors as of May 15:

College of Medicine, University of Tennessee Health Science Center LeBonheur Children's Hospital MAG Mutual Insurance Company Primary Care Education Consortium State Volunteer Mutual Insurance Company Tennessee Rural Partnership

Note: Gatlinburg is a resort city with casual/business casual clothing the acceptable dress for the Tennessee AFP Annual Assembly, excluding the Wednesday's President's Banquet where Sunday dress is requested, and Thursday when Halloween Costumes are encouraged to be worn. (Important ---Gatlinburg, Tennessee is located in the Eastern Time Zone)

IMPORTANT ­ There is no on-site internet service available at the Gatlinburg Convention Center.

TENNESSEE ACADEMY OF FAMILY PHYSICIANS 63rd ANNUAL SCIENTIFIC ASSEMBLY Convention Center, Gatlinburg, Tennessee, October 25-28, 2011

TUESDAY, OCTOBER 25:

9:00 a.m.­6:00 p.m. 9:00 a.m.­5:00 p.m. 12:00 noon­2:00 p.m. TNAFP Physician and Exhibitor Registration Desks Open Exhibit Booth Set-Up ­ Exhibit Hall Open Only to Exhibiting Representatives Note: All exhibit booth setups are to be completed by 5:00 p.m. No exceptions! "Dealing with Difficult Colleagues" (Risk Management Seminar by State Volunteer Mutual Insurance Company) Physicians insured by SVMIC who attend this seminar will qualify for a 10% premium credit. SVMIC fees: $50 per physician policy holder; $15 non-physician employee. See special pre-registration form provided in back of this brochure. *Note: Registration for SVMIC seminar only does NOT allow access to the TNAFP annual scientific assembly sessions, workshops, exhibits or functions. TENNESSSEE AFP CONGRESS OF DELEGATES' MEETING ­ Lang Smith, M.D., MPH, Speaker- Presiding

3:00 p.m.­6:00 p.m.

WEDNESDAY, OCTOBER 26:

7:00 a.m.-5:00 p.m. 7:30 a.m.-8:00 a.m. 7:50 a.m.-8:00 a.m. 8:00 a.m.-8:30 a.m. 8:00 a.m. 8:30 a.m.-9:30 a.m. 9:00 a.m. 9:30 a.m.-10:15 a.m. 10:15 a.m.-11:00 a.m. 11:00 a.m.-11:45 a.m. 11:45 a.m.-12:00 noon 12:00 noon-1:00 p.m.

TNAFP Physician and Exhibitor Registration Desks Open Light Continental Breakfast for Paid Registered Attendees (Supported by College of Medicine, UT Health Science Center) `WELCOME & ANNOUNCEMENTS' ­ Wes Dean, M.D., FAAFP, 2011 TNAFP President

"GREETINGS & UPDATE FROM THE AAFP" ­ Glenn Stream, M.D., FAAFP, 2011 AAFP President-Elect

Exhibit Hall Opens to Exhibitors Only "Asthma" - Tim Vega, M.D. Exhibit Hall Opens (Coffee Service Supported by MAG Mutual) FOOD/BEVERAGE BREAK ­ VISIT EXHIBITS "Celiac Disease: A Hidden Epidemic" - Peter HR Green, M.D. "Evaluation and Treatment of Vaginal Bleeding" - Reid Blackwelder, M.D., FAAFP Research Paper Presentation #1 (From Resident & Student Research Paper Competition) LUNCH ­ VISIT EXHIBITS

+During Lunch on Wednesday, Russ Leftwich, M.D., Chief Medical Informatics Officer, Office of eHealth Initiatives,StateofTennessee,willbeavailabletomeetwithinterestedattendeesforanopenforum on EHR adoption, Health Information Exchange, Direct Project, and EHR Incentive programs.

12:00 noon-1:00 p.m. 1:00 p.m.-1:45 p.m. 1:45 p.m.-2:30 p.m. 2:30 p.m.-3:15 p.m. 3:15 p.m.-4:00 p.m. 3:30 p.m.

TNAFP LEGISLATIVE COMMITTEE MEETING/LUNCH "Evidence Based CVD Prevention" - Gregg Mitchell, M.D.

"Osteoporosis" - Reid Blackwelder, M.D., FAAFP FOOD/BEVERAGE BREAK ­ VISIT EXHIBITS "Childhood Obesity Epidemic in Tennessee" - Rick Canada Exhibit Hall Closes for the Day

WEDNESDAY, OCTOBER 26 (continued):

4:00 p.m.-4:45 p.m. 4:45 p.m. to 5:00 p.m. 6:30 p.m.-8:30 p.m. "Advocating for Healthy Community Design" - Kathleen Beine, M.D. Announcements-Daily Door Prize Drawings-Adjournment of Scientific Sessions for the Day ANNUAL PRESIDENT'S BANQUET (Charge of $35.00 each) Sunday Dress

Hosted by 2011 TNAFP President, Wes Dean, M.D., FAAFP Installation of 2012 TNAFP Officers and Board of Directors by 2011 AAFP President-elect ­ Glen Stream, M.D., Spokane, WA Presentation of 2011 TNAFP Family Physician of the Year Award and John S. Derryberry, M.D. Distinguished Service Award. AAFP Degree of Fellow Convocation

THURSDAY, OCTOBER 27:

7:00 a.m.-5:00 p.m. 7:30 a.m.-8:00 a.m. 8:00 a.m. 8:00 a.m.-8:45 a.m. 8:45 a.m.-9:30 a.m. 9:00 a.m. 9:30 a.m.-10:15 a.m. 10:15 a.m.-11:00 a.m. 11:00 a.m.-11:45 a.m. 11:45 a.m.-12:00 noon 12:00 noon-1:00 p.m. 1:00 p.m.-1:45 p.m. 1:45 p.m.-2:30 p.m. 2:30 p.m.-3:15 p.m. 3:15 p.m.-3:30 p.m. 3:30 p.m.-4:30 p.m. TNAFP Physician and Exhibitor Registration Desks Open Light Continental Breakfast for Paid Registered Attendees Exhibit Hall Opens to Exhibitors Only "Top Ten Articles of the Past Year" - John P. Franko, M.D. "ABFM ­ Latest Information of Help to You" - Joseph W. Tollison, M.D. Exhibit Hall Opens to Attendees (Coffee Service Supported by MAG Mutual) FOOD/BEVERAGE BREAK ­ VISIT EXHIBITS "SAM's Module: Care of the Vulnerable Elderly" - Gregg Mitchell, M.D. "ABFM Recertification: Highlighting Part IV" - Joseph W. Tollison, M.D. Research Paper Presentation #2 (From Resident & Student Research Paper Competition) LUNCH ­ Visit Exhibits

"Immunization Update and Tennessee Web Immunization System (TWIS)" - Kelly L. Moore, M.D., MPH

"Revised Estate Planning" - L. Shane Whitehead and Daniel L. Mills, LUTCF "Alzheimer's Disease" - John H. Dougherty, Jr., M.D. Announcements-Daily Door Prize Drawings-Adjournment of Scientific Sessions for the Day HALLOWEEN PARTY & TRICK-OR-TREATING (Supported by College of Medicine, UT Health Science Center) Costumes strongly encouraged! All attendees including our paid registered attendees, exhibitors and all family members are strongly encouraged to dress in their favorite costume all day on Thursday. Trick-or-treating in the exhibit booths will begin at 3:30 p.m. Snacks will be served. Announcement of the Exhibitors' Costume and Booth Decoration winners. Everyone is asked to please participate and make this a fun time for everyone and especially a fun time for all the children. Exhibit Hall Closes for the Day BOARD OF DIRECTORS' MEETING (Refreshments Supported by Tennessee Rural Partnership)

4:30 p.m. 4:45 p.m­7:00 p.m.

FRIDAY, OCTOBER 28:

7:00 a.m.-1:00 p.m. 7:30 a.m.-8:00 a.m. 8:00 a.m. 8:00 a.m.-8:45 a.m. 8:45 a.m.-9:00 a.m. 9:00 a.m.-9:45 a.m. 9:00 a.m. 9:45 a.m.-10:30 a.m. 10:30 a.m.-11:15 a.m. 10:45 a.m. TNAFP Physician and Exhibitor Registration Desks Open Light Continental Breakfast for Paid Registered Attendees Exhibit Hall Opens to Exhibitors Only "Supplements in Athletics" - Daniel Lewis, M.D., CAQSM Research Paper Presentation #3 (From Resident & Student Research Paper Competition) "Pediatric Dermatology" - James E. Turner, M.D., PhD, MS Exhibit Hall Opens to Attendees FOOD/BEVERAGE BREAK ­ VISIT EXHIBITS "Evaluation of Febrile Illness in Returning International Travelers and Wilderness Explorers" ­ M. David Stockton, M.D., MPH Exhibit Removal Begins

11:15 a.m.-12:00 noon - "Pediatric Pain Management" ­ K. J. S. Anand, M.D., FAAP, FCCM, FRCPCH 12:00 noon-1:00 p.m. "Physician Prescribing and Monitoring of Scheduled Drugs" - Lang Smith, M.D., MPH "Physician Prescribing and Monitoring of Scheduled Drugs" will satisfy the State of Tennessee's Board of Medical Examiner's continuing medical education requirement of one hour every two years of prescribing practices for medical licensure Special Note: Registration for only `Physician Prescribing and Monitoring of Scheduled Drugs" is available for a $50.00 registration fee if you are NOT attending the entire Tennessee AFP Annual Assembly. For 2011 Annual Assembly registered attendees, there is no additional fee; this presentation is included in your annual assembly registration fee. 1:00 p.m. ­ 1:15 p.m. Final Announcements - Drawing for Exhibit Booth Attendance Grand Door Prize Final Adjournment of 2011 Tennessee AFP Annual Scientific Assembly

Tennessee AFP to Make Group Donation of Sample Medications to the Dispensary of Hope!

The Dispensary of Hope, an exhibitor at our Annual Assembly for the past three years, needs the Tennessee AFP's help. Based in Tennessee, the Dispensary of Hope is a not-for-profit social venture that provides pharmaceutical access to low-income and uninsured patients in our state and across the country. Their mission is possible thanks to generous donations of sample medications from individual physicians and groups like the Tennessee AFP. At this year's Annual Scientific Assembly on October 25-28 in Gatlinburg, the TNAFP will be making a group donation of sample medication to the Dispensary of Hope. We encourage you to bring any unexpired, non-controlled samples to Gatlinburg for donation to the Dispensary of Hope at their booth. The Dispensary of Hope will announce TNAFP's total donation amount after the conference. If you are not attending this year's Tennessee AFP's Annual Scientific Assembly but would still like to make a donation, contact Vicki Jones at the Dispensary of Hope at 615-736-5595 or victoria.jones@dispensaryofhope.org. On behalf of the Dispensary of Hope, the Tennessee AFP thanks you for your participation!

FACULTY

TENNESSEE ACADEMY OF FAMILY PHYSICIANS' 63rd ANNUAL SCIENTIFIC ASSEMBLY

Glen Stream, M.D., FAAFP ­ 2011 President-Elect, American Academy of Family Physicians; Spokane, WA Tim Vega, M.D. ­ Medical Director, Business and Community Health, OSF Saint Francis Medical Center; Medical Director, OSF Health Management; Peoria, IL Peter HR Green, M.D. ­ Professor of Clinical Medicine, College of Physicians and Surgeons, Columbia University; Director, Celiac Disease Center at Columbia University; New York, NY Reid Blackwelder, M.D., FAAFP ­ Professor of Family Medicine, Quillen College of Medicine, ETSU; Kingsport, TN Gregg Mitchell, M.D. ­ Associate Professor and Program Director, University of Tennessee Jackson Family Medicine Residency; Tennessee AFP President-elect; Jackson, TN Rick Canada ­ Director of Nutrition, Physical Education and Obesity, State of Tennessee, Department of Health; Nashville, TN Kathleen Beine, M.D. ­ Clinical Associate Professor, Department of Family Medicine, ETSU; Principal Researcher and Consultant, Beine & Associates; Kingsport, TN John P. Franko, M.D. ­ Chair, Department of Family Medicine, Quillen College of Medicine, ETSU; Johnson City, TN Joseph W. Tollison, M.D. ­ Senior Advisor to the President, American Board of Family Medicine; Evans, GA Kelly Moore, M.D., MPH ­ Medical Director, Tennessee Immunization Program; Assistant Clinical Professor of Preventive Medicine, Vanderbilt School of Medicine; Nashville, TN L. Shane Whitehead ­ Registered Representative, MDRT; Financial Services Representative & Princor Registered Representative, Principal Financial Group; Brentwood, TN Daniel L. Mills, LUTCF ­ Managing Director, Princor Registered Representative, Investment Advisor Representative, Principal Financial Group; Brentwood, TN John H. Dougherty, Jr., M.D. ­ Associate Professor, University of Tennessee; Director of Cole Neuroscience Center, Memory Disorder Program; Knoxville, TN Daniel Lewis, M.D., CAQSM ­ Family Physician; Greeneville, TN James E. Turner, M.D., PhD, MS ­ Clinical Professor, University of Tennessee; Mid-South Dermatology; Memphis, TN M. David Stockton, M.D., MPH ­ Professor, Department of Family Medicine, UT Graduate School of Medicine; Knoxville, TN K. J. S. Anand, M.D., FAAP, FCCM, FRCPCH ­ Professor of Pediatrics, Anesthesiology & Neurobiology, St. Jude Chair, Critical Care Medicine, Division Chief, Pediatric Critical Care Medicine, LeBonheur Children's Hospital, University of Tennessee Health Science Center; Memphis, TN Lang Smith, M.D., MPH ­ Family Physician, Tennessee Department of Health; Columbia, TN

(Listed in order of date & time for speaking)

TENNESSEE AFP EXHBITORS AS OF MAY 15, 2011:

Abbott Amedisys Home Healthcare Amedisys Hospice Ameritox Belk & Associates, Inc. Bethel University PA Program BlueCross BlueShield of Tennessee Bureau of TennCare Caris Healthcare Covidien DeRoyal Dispensary of Hope Dominion Diagnostics East TN State University Kowa Pharmaceuticals America, Inc. LeBonheur Children's Hospital LMU - DeBusk College of Osteopathic Medicine MAG Mutual Insurance Company Next Generation Imaging Novartis PathGroup Performance Business Forms, Inc. Pfizer Vaccines Primary Care Diagnostics Principal Financial Group ProAssurance QSource Rural Health Association of Tennessee SJ Pharmaceuticals St. Jude Children's Research Hospital SVMIC Takeda Pharmaceuticals TeamHealth Tennessee Academy of Physician Assistants Tennessee Dept. of Health, Communicable & Environmental Disease Service Tennessee Regulatory Authority Tennessee Rural Partnership tnREC United Healthcare Community and State Univ. of Tennessee Family Medicine Residency Program UT Graduate Medical Education Vanderbilt Univ. Med. Ctr.

The Tennessee Academy of Family Physicians gratefully acknowledges the support of our 2011 Exhibitors. Thanks so very much to all of you!!!

ROOM RESERVATIONS

TENNESSEE ACADEMY OF FAMILY PHYSICIANS 63rd ANNUAL SCIENTIFIC ASSEMBLY OCTOBER 25-28, 2011, GATLINBURG

Blocks of rooms have been reserved at hotels listed below under the name of the Tennessee Academy of Family Physicians. (The Clarion Inn & Suites serves as headquarters hotel for the Tennessee AFP.) Please be sure to inform all hotels holding room blocks for the Tennessee AFP when making reservations that you are with the Tennessee Academy of Family Physicians so group rates will apply. (Note: There are numerous accommodations available in Gatlinburg and surrounding areas. You can access information via the Gatlinburg Chamber of Commerce website at: www.gatlinburg.com. If you do not have internet service and need assistance with accommodations, please call the Tennessee AFP office at 1-800-897-5949.) The Gatlinburg Convention Center is located at the corner of The Parkway and Historic Nature Trail.

ROOM BLOCKS (RATES):

(1) Clarion Inn

1100 The Parkway ($145+rooms;$195+suites)(headquarters)

PHONE NUMBERS:

1-800-933-0777, ext. 135; 1-865-436-5656

CUT-OFF DATES:

9/29/2011

(2) Microtel

211 Historic Nature Trail (Single-$64.95+; Double-$76.95+; Suites-$86.95+)

1-866-399-0107; 1-865-436-0107

9/9/2011

(3) Glenstone Lodge

504 Historic Nature Trail ($85+)

1-800-362-9522; 1-865-436-9361

10/3/2011

(3) Garden Plaza Hotel

520 Historic Nature Trail ($67.99+)

1-800-435-9201; 1-865-436-9201

10/15/2011

(3) Holiday Inn Club Vacation Condos

404 Historic Nature Trail ($149+1 bedroom; $203+2 bedroom)

1-866-327-3014 (Code-TFP) www.holidayinn.com/gatlinburgtn (Code-TFP)

9/24/2011

+Means all room prices above do NOT include taxes. * A one-night deposit check (made to the hotel) or credit card is REQUIRED for ALL room reservations at all hotels. *At least a 72-hour notice of cancellation is required for a refund at all hotels listed above.

PRE-REGISTRATION FORM

TENNESSEE ACADEMY OF FAMILY PHYSICIANS 63rd ANNUAL SCIENTIFIC ASSEMBLY OCTOBER 25-28, 2011; GATLINBURG CONVENTION CENTER

Your registration fee covers all scientific sessions and functions except for the President's Banquet on Wednesday evening, and where additional fee(s) are indicated on this registration form.

MAKE YOUR REGISTRATION CHECK TO ­ Tennessee Academy of Family Physicians Note: The Tennessee Academy of Family Physicians does NOT accept credit cards in payment of fees.

Names for all attendees must be provided to obtain a TNAFP badge which is required for admission to all educational sessions, all functions and the TNAFP exhibit hall. No badge; no entrance. Please clearly print all information on registration form.

YOUR NAME: _____________________________________________________________________________________ ___M.D. ____D.O. ____P.A. ____N.P. ____R.N. Other:_________________________

*NAME AS YOU WISH PRINTED ON YOUR BADGE:__________________________________________________ NAME SPOUSE/SIGNIFICANT OTHER ATTENDING (limited to one person):_________________________________ NAME GUEST(S) ATTENDING: ______________________________________________________________________ NAMES OF CHILDREN & AGES: ____________________________________________________________________ PHONE: (______)_____________________________ FAX: (______)___________________________________

EMAIL:___________________________________________________________________________________________ ADDRESS: ________________________________________________________________________________________ CITY:_____________________________________________ STATE:_____________ ZIP:_______________________ Medical Students and Residents-You must provide the name, city & state of your medical school or residency program and your anticipated completion date:____________________________________________________________________ NOTE ­ There is no on-site internet service available at the Gatlinburg Convention Center.

RETURN THIS COMPLETED REGISTRATION FORM BY FRIDAY, OCTOBER 14 TO ­ TENNESSEE ACADEMY OF FAMILY PHYSICIANS 500 Wilson Pike Circle, Suite 212, Brentwood, TN 37027 Fax: 615-370-5199 Phone: 1-800-897-5949; 615-370-5144

*Please do not mail or fax registration to the Tennessee AFP office after Friday, October 14. *After October 14 no pre-registration will be accepted and registration will only be available on-site at the Tennessee AFP meeting with on-site fees payable.

Continued next page..........

Most Important: Please return Both Front & Back of Registration Form When You Submit Your Pre-Registration

TNAFP 2011 Annual Meeting, Registration Form, Page #2

Tennessee AFP Adopted Board Policy:

***Full registration fee paid includes only one additional adult be it your spouse, significant other or guest (not to include a member's spouse who is a health professional seeking CME who would pay the member registration fee) and all of the Paid Registered Attendee's children age 18 and under at no charge. ^Names for all persons who will be attending under your registration fee paid and receiving a TNAFP badge to access the exhibit hall and food functions, must be provided on this registration form. ^Additional persons attending with you who are non-medical guests, excluding one adult guest who is included in your registration fee, are charged a $25 fee to cover food costs. ^Additional persons attending with you who are health/medical professionals seeking CME credit for attendance at this scientific assembly must pay the appropriate fee listed below.

REGISTRATION FEES:

***AAFP Member AAFP Member Spouse Who is Health Professional Seeking CME ***Tennessee AFP Life Member (age 70+) ***Non-AAFP Member ***Resident ***Medical Student Additional Non-Medical Adult Guests of Paid Registrant (Excludes one adult covered by member registration)

Pre-Registration At-Meeting $ 250.00 $ 250.00 $ 100.00 $ 350.00 $ 35.00 $ 25.00 $ 25.00 $ 350.00 $ 350.00 $ 100.00 $ 450.00 $ 35.00 $ 25.00 $ 25.00

# To Attend ________ ________ ________ ________ ________ ________ ________

Amount $____________ $____________ $____________ $____________ $____________ $____________ $____________

REGISTRATION FRIDAY `PRESCRIBING PRACTICES' ONLY:

Registration for ONLY "Physician Prescribing and $ 50.00 Monitoring of Scheduled Drugs" is available for a $50.00 registration fee if you are NOT attending the entire Tennessee AFP Annual Assembly. NOTE: For 2011 Annual Assembly registered attendees, there is no additional fee; this presentation is included in your annual assembly registration fee. $ 50.00

_______

$____________

FUNCTION RESERVATIONS REQUIRED:

Wednesday, 10/26:

President's Banquet ($35 each)

Any dietary restrictions for Banquet:__________________________________________ ________ $____________

TOTAL PAID

$_________________

TOTAL OWED $_________________

Note: The Tennessee Academy of Family Physicians does NOT accept credit cards in payment of fees.

If cancellation is necessary after registration has been received by the TNAFP, refunds will be made less a $25 administrative charge if cancellation is received IN WRITING by the TNAFP prior to Friday, October 14, 2011. After this date, no refunds can be made.

RETURN THIS COMPLETED REGISTRATION FORM BY FRIDAY, OCTOBER 14 TO ­ TENNESSEE ACADEMY OF FAMILY PHYSICIANS 500 Wilson Pike Circle, Suite 212, Brentwood, TN 37027 Fax: 615-370-5199 Phone: 1-800-897-5949; 615-370-5144

*Please do not mail or fax registration to the Tennessee AFP office after Friday, October 14. *After October 14 no pre-registration will be accepted and registration will only be available on-site at the Tennessee AFP meeting with on-site fees payable.

2011 State Volunteer Mutual Insurance Company's

Risk Management Seminar ­ "Dealing with Difficult Colleagues"

Held During the Tennessee Academy of Family Physicians' 63rd Annual Scientific Assembly Tuesday, October 25, 2011 ­ 12:00 noon to 2:00 p.m. (eastern time) NOTE: This is a courtesy registration form to be used ONLY for registration for your attendance at State Volunteer Mutual Insurance's `Risk Management Seminar' held in conjunction with the Tennessee AFP's 2011 Annual Assembly. Please provide a SEPARATE check made to SVMIC for your SVMIC registration fee(s). And please return this registration form directly to SVMIC, not to the Tennessee AFP office. Registration for SVMIC seminar only does not allow access to the Tennessee AFP annual scientific assembly sessions, workshops, exhibits or functions. (Seminar #1574) Fees: $50.00 per physician policyholder (Earn 10% insurance premium credit plus CME credits.)

$15.00 per non-physician employee (No premium credit for this course.)

YOUR NAME:_____________________________________________________________________________________ YOUR ADDRESS: _________________________________________________________________________________ CITY/STATE/ZIP: _________________________________________________________________________________ TENN. MEDICAL LICENSE #:__________________________________ LAST 4 DIGITS SS #:_______________

PHONE: __________________________________________________________________________________________ FAX (to receive confirmation):________________________________________________________________________ EMAIL ADDRESS (to receive confirmation): ___________________________________________________________ Credit Card Payment Information: ___MC Credit Card Receipt? ___Yes ___No ___Visa ____AE

(Credit card receipt will be faxed or emailed with confirmation.)

Name As It Appears On Credit Card: ____________________________________________________________________ Credit Card Number:_______________________________________ Exp. Date: ______________________________

Your Signature: _____________________________________________________________________________________ Fax registration form and credit card information to our secured fax at 615-846-1783; or, you may mail your registration form with your credit card information to: SVMIC Seminars, P.O. Box 1065, Nashville, TN 37024-1065. If paying by check, mail registration form and appropriate fee to: SVMIC Seminars, MSC Box 30400, P.O. Box 41500, Nashville, TN 37241-5000. SVMIC's "20-MINUTE RULE":

Please be advised of SVMIC's "20-minute rule." Policyholders attending an SVMIC seminar for credit must participate in the entire program to fully benefit from the program and qualify for a 10 percent premium discount. We will count in attendance only those participants who are registered and signed in within the first 20 minutes of the seminar. There are multiple seminars given throughout the year. If participants are unable to present within this time frame, they will be expected to attend a later seminar or take an approved self-study or on-line course. Late registrants will no longer be considered present for satisfaction of the 10 percent credit. A complete schedule is available at: www.svmic.com

CME APPROVAL:

This program has been reviewed and is acceptable for up to 2 Prescribed credits by the American Academy of Family Physicians. AAFP prescribed credit is acceptable by the AMA as equivalent to AMA PRA Category I for the AMA Physicians Recognition Award. (When applying for the AMA PRA, prescribed hours earned must be reported as prescribed hours, not as Category I.)

*Registration and payment for SVMIC Seminar must be submitted directly to SVMIC, not to the Tennessee AFP.

TENNESSEE ACADEMY OF FAMILY PHYSICIANS

500 WILSON PIKE CIRCLE, SUITE 212, BRENTWOOD, TN 37027 PHONE: 1-800-897-5949 · 615-370-5144 FAX: 615-370-5199

PRSRT STD U.S. POSTAGE NASHVILLE, TN PERMIT NO. 1528

PAID

TENNESSEE ACADEMY OF FAMILY PHYSICIANS

63rd AnnuAl Assembly & scientific ProgrAm

Convention Center Gatlinburg, Tennessee October 25-28, 2011

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