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

Basic Information

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.

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* 1. First Name

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* 2. Middle Initial

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* 3. Last Name

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* 4. E-Mail Address

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

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* 6. Healthcare Role

M.D.

D.O.

Other Healthcare Providers (please specify)

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* 7. Practice Specialty

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* 8. California MD/DO/Other Healthcare Providers License #

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* 9. How did you hear about this activity?

CAMASC Invitation

Colleague Invitation

Website Visit

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* 10. Are you a CAMASC member?

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

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

Yes

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* 1. First Name

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* 2. Middle Initial

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* 3. Last Name

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* 4. E-Mail Address

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

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* 6. Healthcare Role

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* 7. Practice Specialty

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* 8. California MD/DO/Other Healthcare Providers License #

Question Title

* 9. How did you hear about this activity?

Question Title

* 10. Are you a CAMASC member?

Question Title

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

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