American Medical Association

Current Procedural Terminology®

Internal Use License Application

Company Name:
Parent Company:
Address:
City: / State: / Zip Code:
Country:
Contact Person: / Title:
Telephone:
() / Facsimile:
()
E-mail:
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 Internal Use of CPT® Codes

1. In what software or type of system will the CPT data be used? Is there a name for the system?

2. CPT data is licensed based on the number of individual end users who access it in your system. How many of your employees will have access to the CPT data in your system?

3. How will the CPT data be used internally?

4. Will the CPT data be accessed by users who are not directly employed by you at a separate legal entity (e.g., parent companies, subsidiaries, clinics)? Yes No

If yes, please explain.

5. Will CPT data be accessed by any users outside of the United States?

Yes No

If yes, in which countries?

If yes, is your organization part of any government?
Yes No

6. Will your use of CPT data include the Internet?

If yes, please explain. Yes No

7. Will the product include the AMA’s version of ICD-9-CM?

Yes No

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

Yes No

8. Deliver format (check one only).

CD Email

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