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* 1. Name

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* 3. Your organization or practice/ group name

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* 4. Your organization or practice/ group NPI number

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* 5. Phone number

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* 6. Email address

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* 7. Number of people from your organization who wish to attend the training

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* 8. Is your organization contracted with AmeriHealth Caritas North Carolina?

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* 9. If not, would you like your Regional Account Executive to contact you about joining our network?

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