*1.Please provide your contact information.(Required.)

First and last name

Credentials (such as CPC, RHIT, etc.; if none please enter N/A)

Company

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

*2.What NAHRI/HCPro training have you used in the past? Select all that apply. (Note: It is not a requirement to have used/attended/purchased any NAHRI/HCPro training in the past.)(Required.)

NAHRI membership

Revenue Integrity Essential Skills Online Learning

Medicare Boot Camp (any version)

Revenue Integrity Symposium

CHRI Exam

CHRI Exam Study Guide

CHRI Practice Exam

Core Functions of Revenue Integrity

Other (please specify)

None of the above

*3.Please attach a resume.(Required.)

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*4.Personal statement. Please attach a personal statement explaining your financial need for the scholarship and how you, your organization, or community will benefit from your attendance at the Revenue Integrity Symposium. Please include your name, credentials (if applicable), job title, and a brief overview of your organization, including its size, services offered, population served, and whether it is non-profit or for-profit.(Required.)

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*5.Letter of support. Please attach a letter of support from a professional contact at your organization endorsing your scholarship application. The letter should speak to the applicant’s commitment to the revenue integrity profession and support for the applicant’s attendance at the Revenue Integrity Symposium. (Note: Please bear in mind that the scholarship recipient and/or the scholarship recipient’s organization is responsible for all travel expenses; the scholarship covers only the cost of registration.)(Required.)

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*6.By typing your name and the date in the textbox below you hereby attest that all the information provided in this application is true and accurate to the best of your knowledge.(Required.)