2017 Case Study Submission Form

Purpose

Submit a challenging patient case in the areas of dyslipidemia, cardiovascular disease, hypertension, heart failure, obesity, or type 2 diabetes to be discussed by an expert faculty panel during the general sessions at the 12th Annual CMHC meeting.

Live Discussion Format

2 to 3 patient cases will be discussed by a multidisciplinary expert panel the 4 session tracks (please see the Agenda for more details)
- Session I: Challenging Lipid Cases
- Session II: Lifestyle and Obesity Management in the Cardiometabolic Patient
- Session III: Challenging T2DM Patient Cases
- Session IV: Challenging Patient Cases in Hypertension, Cardio-Renal, and Heart Failure
Engage in an interactive learning format and find answers to your most perplexing clinical case questions

Why Should I Submit a Case?

Participants who submit a patient case will earn 50% off registration to the 12th Annual CMHC meeting in Boston 2017*, OR free registration to any one of our three regional events in 2018.
Selection of a patient case will result in a FREE registration to our 13th Annual CMHC in Boston and acknowledgement from the presenting faculty.

Submission Deadline:

August 15, 2017

*This discount cannot be applied to previous registrations associated with other pricing discounts.
*Fields in bold are required.

Contact Information

First Name:

Last Name:

Phone:

E-mail:

Your Practice

Degree:

Specialties:

Address:

Address 2:

City:

State:

Zip:

Country:

Case Study

For your patient case to be considered, please provide the following details:
Word Count Limit to: 1,000 words

Disease state (i.e. hypercholesterolemia, type 2 diabetes, hypertension, etc.)
Patient case introduction†:

Patient sex, age, race
Indication for medication that requires prior authorization

Any pertinent information that is necessary for the prior authorization process (i.e. past medical history, physical exam results (i.e. BMI, blood pressure, etc.), laboratory results pertinent to the case, past and current medications)
Specific challenges encountered during the prior authorization process for the recommended medication and questions that you would like specifically addressed regarding the prior authorization process

† Please do not include patient name, social security number, medical identification number, or any information specific to the patient's identity.
‡ There is no limit to the number of patient cases you may submit. Submission is free.
Provide the above information as one or multiple files (MS Word or PDF) using the file upload fields below:

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