Open Meeting Presenter Registration

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, May 23, 2024	1pm ET	via webinar
JH/JL Novitas Meeting Friday, May 24, 2024	10am ET 9am CT 8am MT	via webinar

Question Title

* 1. Which meeting will you present at?

First Coast only

Novitas only

both First Coast and Novitas

Question Title

* 2. Please complete the following:

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 3. Your company and title:

Company

Title

Question Title

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

Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

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

Question Title

* 5. How will you be presenting?

via webinar

Question Title

* 6. Do you have any visual or hearing impairments?

Yes

If so, please describe: