Registration Form

Webinar Registration

Please enter your registration information.

Internet e-mail is not a secure media. Please do not send email containing confidential items (e.g., Patient Names, Medicare Numbers, Social Security Numbers). If you have a question about a specific Medicare claim, please contact our offices by another method. This form is only to be used for registering for the Webinars.

Please note: Registrations must be submitted at least 3 days before the date of the webinar. After your registration process is complete, important instructions for accessing the webinar will be sent to your e-mail at least 2 days prior to the session.

Registration Form

First Name:

Last Name:

Company Information

Company Name:	*
Address:	*
City:	*
Suite #:	* (put n/a if not applicable)
State:	*
Zip Code:	*

Mailing Address Click if same as Company Address

Address:	*
City:	*
Suite #:	* (put n/a if not applicable)
State:	*
Zip Code:	*

Telephone:

Specialty :

Email Address:

Does your physician office employ fewer than 10 full-time equivalents?

Yes No

Please choose a Webinar:

Comments:

* - Required information

Please click the Submit button only once. Thank you!

Please supply a VALID e-mail address in order to receive a confirmation for your selected Workshop.

05/01/2008