Current Procedural Terminology

Distribution License Application

All fields are required to be completed prior to submission of this license application.

Product Name:
Company Name:
Parent Company:
Address:
City: / State: / Zip Code:
Country:
Contact Person: / Title:

Telephone:
() / Facsimile:
()

E-Mail: Web Address:
The American Medical Association (AMA) agrees that the information provided by applicants will be kept confidential. I agree to keep the information provided by the AMA confidential. I confirm that all responses and related documentation submitted as part of the application process are accurate and complete to the
best of my knowledge. I agree that I will notify the AMA if the information changes.
Signature: / Title:
Print Name: / Date:

CPT® is a registered trademark of the American Medical Association.

Application For Use of CPT® Codes

1. Product format (check all that apply):

Electronic Media Print Internet

If product is accessed via the Internet, give Web address:

2. Describe the product in sufficient detail to give a conceptual understanding.

Describe how CPT codes and descriptions will be used in the product.

3. Select all that product categories that apply:

Ambulatory Only EMR
Analytics
Clinical & Ambulatory EMR
Clinical Only EMR
Health Information Exchange
Outcomes & Quality Management
Patient Billing
Practice Management
Other (please specify)

4. Attach sample pages and/or screen shots from the product showing how CPT

material is used and displayed.

5. Redistribution of CPT material alone is not permitted; licensed products must

include additional code-level content (i.e., content that appears when codes

are displayed). For example, in an electronic medial record, the added content

would be the patient encounter information such as date, patient name, and

diagnosis. List the additional code-level content that will be contained in the

product.

6. Describe the intended use, the target market and the projected sales price of the

product.

7. Will the product include the AMA’s version of ICD-10-CM?

Yes No

8. Will the product include the AMA’s version of HCPCS?

Yes No

9. Do or will your marketing or promotional materials refer to CPT or the AMA?

Yes No

If yes, PLEASE NOTE: Representative samples of marketing or promotional

materials referring to CPT and all marketing or promotional materials referring to

the name, initials or logo of the AMA must be reviewed and approved. To initiate

this review, please attach relevant materials. If not currently available, please

forward as they become available.

10. Please provide a projection of sales for the product for which you are seeking a license:

Year 1: ______

Year 2: ______

Year 3: ______

11: What is the pricing model for the product? (Note: AMA licenses CPT on a per user basis. A user is defined as an individual who: (a) accesses, uses, or manipulates CPT Editorial Content contained in the Electronic Licensed Product; or (b) accesses, uses, or manipulates the Electronic Licensed Product to produce or enable an output (data, reports, or the like) that could not have been created without the CPT embedded in the Electronic Licensed Product even though CPT Editorial Content may not be visible or directly accessible; or (c) makes use of an output of the Electronic Licensed Product that relies on or could not have been created without the CPT Editorial Content embedded in the Electronic Licensed Product even though CPT Editorial Content may not be visible or directly accessible.

12. What is the target distribution date? If currently distributed, give date of first

distribution.

13. In which countries will the product be distributed?

14. Provide a summary of company’s history. Include the date of incorporation,

principal officers, length of business and parent and subsidiary companies if

applicable.

NOTE:

Effective August 1, 2016, an Upfront Annual Royalty Fee a $1,000, is due for each calendar year during the Term of this Agreement. The Upfront Annual Royalty Fee is due prior to the execution of this Agreement by the AMA, and an additional Upfront Annual Royalty Fee is due no later than July 31 of each year thereafter during the Term of this Agreement.