CPESN USA Clinically Integrated Network Training
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First Name
Last Name
Email
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example@example.com
Select Role(s) for the Reason Completing Clinically Integrated Network (CIN) Training (select all that apply)
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Pharmacy Staff
CPESN Network Leader
Board Member / Participant
CPESN Committee Member / Participant
Sub-Committee Member / Participant
Student Pharmacist on rotation
Other - Include role and affiliation for completing (e.g., network facilitator for CPESN Medical Billing Supports as an SPP)
Select CPESN Network Affiliation
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AlignRx CPESN
Arizona CPESN
Arkansas CPESN
CPESN Alabama
CPESN Alaska
CPESN California
CPESN Colorado
CPESN DMV
CPESN Florida
CPESN Hawaii
CPESN Indiana
CPESN Iowa
CPESN Kansas
CPESN Kentucky
CPESN Louisiana
CPESN Michigan
CPESN Minnesota
CPESN Mississippi
CPESN Missouri
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CPESN New England
CPESN New Jersey
CPESN New Mexico
CPESN North Carolina
CPESN North East Tennessee
CPESN Georgia
CPESN of New York City
CPESN New York Upstate
CPESN of Western New York
CPESN Ohio
CPESN Oregon
CPESN South Carolina
CPESN Tennessee
CPESN Texas
CPESN Utah
CPESN Virginia
CPESN Washington
CPESN West Virginia
CPESN Wisconsin
CPESN Wyoming
Illinois I CPEN
Pennsylvania Pharmacists Care Network
South Dakota CPESN
CPESN Network Leader Role (check all that apply)
Network Luminary
Next Generation Luminary
Managing Network Facilitator
Network Facilitator
Account Manager
Beacon
Student Pharmacist / Intern
Your role with pharmacy (check all that apply)
Pharmacy Owner
Pharmacist in Charge
Staff Pharmacist
Pharmacy Technician
Business Lead
Clinical Programs Lead
Pharmacy Name
Pharmacy NPI
School/College of Pharmacy Name
I attest the current CPESN USA Clinically Integrated Network Training videos have been viewed to entirety.
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