BTI Training Registration Form We are currently accepting registration for: 2021 Spring Sessions February 2-4, 2021 OK Question Title * 1. Contact Information Name * Organization * Address * Address 2 City/Town * State * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP Code * Credentials Email Address * Phone Number * OK Question Title * 2. Did you attend our BTI Training in November 2020? If yes, please specify which training. Pharmacotherapy Low Dose CT Screening Motivational Interviewing I have not previously attended BTI Training OK Question Title * 3. Which dates do you plan on attending? February 2 - Pharmacotherapy February 3 - Low Dose CT Screening February 4 - Motivational Interviewing OK Question Title * 4. BTI is a targeted training system for staff of Arkansas Federally Qualified Healthcare Centers. Are you currently employed with an Arkansas FQHC that provides tobacco cessation counseling? Yes No Name of FQHC and Location OK Question Title * 5. Are you registering as an individual or a group? Individual Group OK Question Title * 6. (Group registration only). Please list Name, Credentials, and Email Address on separate lines for each participant in order for us to contact you. OK Question Title * 7. Please complete this quick survey to help ACC design programs to help healthcare providers better assist patients who use tobacco. Does/would your clinic or healthcare system: Yes No Provide tobacco/nicotine cessation counseling to patients? Provide tobacco/nicotine cessation counseling to patients? Yes Provide tobacco/nicotine cessation counseling to patients? No Receive reimbursement for tobacco/nicotine counseling through Medicare, Medicaid or private insurance? Receive reimbursement for tobacco/nicotine counseling through Medicare, Medicaid or private insurance? Yes Receive reimbursement for tobacco/nicotine counseling through Medicare, Medicaid or private insurance? No Be interested in implementing health system change for patients who use tobacco/nicotine? Be interested in implementing health system change for patients who use tobacco/nicotine? Yes Be interested in implementing health system change for patients who use tobacco/nicotine? No Be interested in hosting/attending a free tobacco cessation training? Be interested in hosting/attending a free tobacco cessation training? Yes Be interested in hosting/attending a free tobacco cessation training? No Be interested in obtaining free Continuing Education Credits? Be interested in obtaining free Continuing Education Credits? Yes Be interested in obtaining free Continuing Education Credits? No Be interested in receiving information on how to bill/code for tobacco cessation counseling? Be interested in receiving information on how to bill/code for tobacco cessation counseling? Yes Be interested in receiving information on how to bill/code for tobacco cessation counseling? No Be interested in receiving a free Carbon Monoxide monitor? Be interested in receiving a free Carbon Monoxide monitor? Yes Be interested in receiving a free Carbon Monoxide monitor? No OK Thank you for your application. ACC will contact you with more details. OK SUBMIT
