ICD-10 Training Registration WELCOME TO THE ICD-10 ONLINE TRAINING REGISTRATION FORM. THE INFORMATION PROVIDED WILL BE USED TO ENROLL PROVIDERS AND THEIR STAFF MEMBERS INTO SELF-PACED ONLINE TRAINING. Question Title * 1. What IPA are you with? Please select all that apply Mercy Physicians Medical Group (MPMG) Physician Partners Medical Group (PPMG) Primary Care of Associated Medical Group (PCA) Primecare of Chino Hills (CHI) Primecare of Citrus Valley (CIT) Coachella Valley Physicians (CVP) Primecare of Corona (COR) Primecare of Hemet Valley (HEM) Primecare of Inland Valley (IVA) Primecare of Moreno Valley (MVA) Primecare of Redlands (RED) Primecare of Riverside (RIV) Primecare of San Bernardino (SAN) Primecare of Sun City (SUN) Primecare of Temecula (TEM) Valley Physicians Network (VPN) Question Title * 2. Physician/Group Name Physician/Group Name: Contact Name: Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Country: Email Address: Phone Number: Please Note: Each online learner will need to have their own contact email address. This is where they will receive their username and password, log-in instructions, and their Quick Start Guide. Question Title * 3. Please provide number of providers for Self-Paced Online Training: IF YOU HAVE MORE THAN 6 PROVIDERS WHO NEED ONLINE TRAINING; PLEASE FILL OUT AN ADDITIONAL REGISTRATION FORM. Question Title * 4. Please provide the following for each provider for online training: 1. Provider's Name: Email Address: Specialty: 2. Provider's Name: Email Address: Specialty: 3. Provider's Name: Email Address: Specialty: 4. Provider's Name: Email Address: Specialty: 5. Provider's Name: Email Address: Specialty: 6. Provider's Name: Email Address: Specialty: Question Title * 5. Please provide number of staff members for Self-Paced Online Training: IF YOU HAVE MORE THAN 6 STAFF MEMBERS WHO NEED ONLINE TRAINING; PLEASE FILL OUT AN ADDITIONAL REGISTRATION FORM. Question Title * 6. Please provide the following for each staff member for online training: 1. Staff Name: Email Address: Job Title: 2. Staff Name: Email Address: Job Title: 3. Staff Name: Email Address: Job Title: 4. Staff Name: Email Address: Job Title: 5. Staff Name: Email Address: Job Title: 6. Staff Name: Email Address: Job Title: ONCE YOUR REGISTRATION INFORMATION HAS BEEN RECEIVED; IT WILL BE SENT OVER TO OPTUM FOR ENROLLMENT. ONCE ENROLLED; EACH LEARNER WILL RECEIVE AN EMAIL NOTIFICATION CONTAINING THEIR LOG-IN INFORMATION AND INSTRUCTIONS. PLEASE ALLOW 3 TO 4 DAYS PROCESSING TIME. Done