Thank you for your interest in attending ACEs Aware trainings/workshops, sponsored by the Riverside County Medical Association. Please fill out this RCMA ACEs Aware Core Training Registration form to get registered.

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* 1. E-mail Address

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* 2. First Name

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* 3. Middle Initial

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* 4. Last Name

For providers seeking Medi-Cal payment, your individual National Provider Identifier (NPI) is required. This information will not be shared publicly.

You can look up your NPI on the CMS NPI Registry public search at https://npiregistry.cms.hhs.gov/.

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* 5. National Provider Identifier

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* 6. Organization

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* 7. Phone Number

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* 8. What is your race? (Select all that apply)

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* 9. Are you Hispanic, Latino/a, or Spanish origin? (Yes or No)

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* 10. Do you see Medi-Cal patients?

For providers seeking Medi-Cal reimbursement, please enter your service address. Your service address is where services are rendered – check with your Medi-Cal billing expert if you have questions.

This information will be used by the California Department of Health Care Services to verify that you are an eligible Medi-Cal Provider. For providers not seeking Medi-Cal reimbursement, please enter your service address to inform the state’s geographic analysis. This information will not be shared publicly.

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* 11. Service Location Street

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* 12. Service Location Additional

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* 13. Service Location City

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* 14. Service Location State/Province

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* 15. Service Location Postal Code

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