Open Meeting Presenter Registration Form Survey

First Coast Service Options and Novitas Solutions, Inc.

Upon completing this form, you will be directed to a confirmation page from SurveyMonkey that will indicate your registration has been received. A separate confirmation email will be sent out to the email address provided in order to obtain more information regarding your presentation.

Note: If you are planning to attend as an observer, please complete the Open Observer Registration.

JN First Coast WebEx Observer Registration

JH/JL Novitas WebEx Observer Registration

Meeting Details

Date	Time	Location
JN First Coast Meeting Thursday, July 23, 2026	1:00pm ET	via webinar
JH/JL Novitas Meeting Friday, July 24, 2026	10am ET 9am CT 8am MT	via webinar

1.Which meeting will you present at? (Note: you will present to the same Contractor Medical Directors at each meeting and your presentation will be reviewed by First Coast and Novitas even if you only present at one of their meetings)(Required.)

First Coast only

Novitas only

both First Coast and Novitas

2.Please complete the following:(Required.)

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

3.Your company and title:(Required.)

Company

Title

4.Which proposed Local Coverage Determination (LCD) will you be presenting on?(Required.)

Facet Joint Interventions for Pain Management

I will be attending as an observer only.
Please Note: This registration form is for presenters only. If you are attending as an observer, please complete the observer registration form only (linked at the top of this form).

5.How will you be presenting?(Required.)

via webinar

6.Do you have any visual or hearing impairments?(Required.)

Yes

If so, please describe: