2019 Blue Advantage® Primary Care Incentive Program

Timely Topics Registration

Thursday November 15, 2018
1:00 p.m. - 2:00 p.m. CST

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* 1. Name:

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* 2. Practice Name:

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* 3. Tax ID:

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* 4. Payee NPI:

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* 5. Email:

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* 6. Office Phone Number:

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* 7. How many associates will be viewing the Timely Topics with you?

Just me

2-3 associates

4-5 associates

6-7 associates

Other (please specify)

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* 8. Specialty:

Primary Care

Pediatrics

OBGYN

Dental

Hospital

Other (please specify)