“Healthcare Provider Educational Fair" (a Non-CME lecture included) 02/27/18 Survey

To register for the upcoming event, please complete the information below.

“How to Avoid the Revocation of Medicare Billing Privileges”

Tuesday, February 27, 2018 at 6:00PM

Empress Harbor Seafood Restaurant
111 N. Atlantic Blvd., Ste. 350
Monterey Park, CA 91754

Dinner will be provided to the first 50 attendees who register by Wednesday, 2/7/18 only.

1.First Name(Required.)

2.Middle Initial

3.Last Name

4.E-Mail Address(Required.)

5.Contact Phone Number
(Please use this format: xxx-xxx-xxxx)(Required.)

6.Healthcare Role(Required.)

M.D.

D.O.

Other Healthcare Providers (please specify)

7.Practice Specialty(Required.)

8.California MD/DO/Other Healthcare Providers License #(Required.)

9.How did you hear about this activity?(Required.)

CAMASC Invitation

Colleague Invitation

Website Visit

10.Are you a CAMASC member?(Required.)

Yes, I am a CAMASC member and have paid the 2018 membership fee of $200.00

I want to become a CAMASC member and would like to pay the 2018 membership fee of $200.00 as a Physician

I want to become a CAMASC member and would like to pay the 2018 membership fee of $80.00 as a Medical Student/Physician-in-Training

I will consider CAMASC membership later

11.Will you require ADA (Americans with Disabilities) accommodations?(Required.)

Yes

No

“Healthcare Provider Educational Fair" (a Non-CME lecture included) 02/27/18