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HEDIS 101 Quarterly Training Registration
HEDIS 101 Training Registration
Please complete each section to register for HEDIS 101 provider training.
*
1.
Practice Information.
(Required.)
Provider, Group, or Facility Name:
Address 1:
Address 2:
City/Town:
State:
ZIP Code:
Email Address:
Phone Number:
Fax Number:
Tax ID Number:
2.
Main Contact for Practice
Name:
Title:
Phone Number:
Email Address:
3.
Please list the names of the practice or facility staff and/or practitioners who will be attending the scheduled training.
Provider Name:
Provider Name:
Provider Name:
Provider Name:
Provider Name:
Provider Name:
Provider Name:
Provider Name:
Provider Name:
Provider Name:
4.
Date of attendance
2/15/2023
6/14/2023
9/13/2023
11/15/2023
02/21/2024
05/22/2024
08/21/2024
11/20/2024
