“Healthcare Provider Educational Fair"
(a Non-CME lecture included)

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

Free registration for CAMASC members.

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. In order to complete the registration for this event, you must be a CAMASC member or a registration fee of $80.00 will be charged.

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 and pay the registration fee of $80.00 only

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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

Question Title

* 4. E-Mail Address

Question Title

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

Question Title

* 6. Healthcare Role

Question Title

* 7. Practice Specialty

Question Title

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

Question Title

* 9. How did you hear about this activity?

Question Title

* 10. In order to complete the registration for this event, you must be a CAMASC member or a registration fee of $80.00 will be charged.

Question Title

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

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