American Society of
Interventional Pain Physicians
The Voice of Interventional Pain Management since 1998
ESSENTIALSIN
PRA...
FROM THE CHAIRMAN
On behalf of the Board of Directors of the American Society
of Interventional Pain Physicians (ASIPP), I...
STATEMENT OF NEED
These two-day comprehensive review courses are planned as a CME
activity to prepare for competency certi...
AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS4
CONTROLLEDSUBSTANCEMANAGEMENT: WHATYOUNEEDTOKNOWCOMPREHENSIVEREVIEWCOU...
AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS 5
ESSENTIALSIN PRACTICEMANAGEMENT INIPMCOMPREHENSIVEREVIEWCOURSEANDCOMP...
PAYMENT METHOD (Please check one):
m MASTERCARD m VISA m AMERICAN EXPRESS m DISCOVER
_____________________________________...
PAYMENT METHOD (Please check one):
m MASTERCARD m VISA m AMERICAN EXPRESS m DISCOVER
_____________________________________...
PRSRTSTD
U.S.POSTAGE
PAID
PADUCAH,KY
PERMIT#44
AmericanSocietyof
InterventionalPainPhysicians
81LakeviewDrive,Paducah,KY42...
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Controlled Substance Management: What You Need to Know Comprehensive Review Course

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Controlled Substance Management: What You Need to Know Comprehensive Review Course

  1. 1. American Society of Interventional Pain Physicians The Voice of Interventional Pain Management since 1998 ESSENTIALSIN PRACTICEMANAGEMENTINIPMCOMPREHENSIVEREVIEWCOURSE ANDCOMPETENCYEXAMINATION UP TO 14.25 AMA PRA CATEGORY 1 CREDITS™ CONTROLLEDSUBSTANCE MANAGEMENTWHATYOUNEEDTOKNOWCOMPREHENSIVEREVIEWCOURSE ANDCOMPETENCYEXAMINATION UP TO 14 AMA PRA CATEGORY 1 CREDITS™ OCTOBER4-6,2013|DENVER,COLORADO HOTEL&REVIEWCOURSELOCATION: The Westin Denver Downtown, 1672 Lawrence Street, Denver, CO 80202 | 1-303-572-9100 SPECIAL DISCOUNTS: • $100 each for InterventionalTechniques in Chronic Spinal Pain and Chronic Non-Spinal Pain • 10% off Foundations, Clinical Aspects, and/or Board Review Self-Assessment • 20% off Essentials of Practice Management: Billing, Coding, and Compliance in Interventional Pain Management • 50% Off Meeting Fee to Fellows & Residents • Special room rates though September 12, 2013 ASIPP® EDUCATIONAL SERVICES | EXCELLENCE IN EDUCATION OF INTERVENTIONAL PAIN PHYSICIANS
  2. 2. FROM THE CHAIRMAN On behalf of the Board of Directors of the American Society of Interventional Pain Physicians (ASIPP), I would like to invite you to one of the most comprehensive and useful educational conferences available anywhere. The ASIPP Comprehensive Review Courses and Exams in Controlled Substance Management and Practice Management will be held in Denver, Colorado, on October 4-6, 2013. Since we began offering the Competency Review courses in 2005, it has become recognized as a “must attend” training event for interventional pain physicians and physicians just entering interventional pain management or in-training and physiciansappearing for board examinations by various boards. The Coding, Compliance and Practice Management is so beneficial to practices, both office-based and ASCs, that many physicians send their staff early to keep them current on the cutting edge aspects of practice management. These intensive review courses are designed to present interventional pain management specialists and other health care providers an in-depth review of multiple areas of interventional pain management—the areas we were never taught, yet are crucial for our survival. The course features many nationally recognized experts in pain management billing and coding and practice management as well as controlled substance management. In today’s environment of regulations and litigations, you can’t afford not to broaden your knowledge and refresh your skills in these areas. In addition to the review course, the American Board of Interventional Pain Physicians (for physicians) and the American Association of Allied Pain Management Professionals (for non-physicians) offers the opportunity for examination in order for physicians to obtain competency certification to and non-physicians to obtain associate certificates in Controlled Substance Management and Coding, Compliance, and Practice Management. We hope you will join us in exciting Denver, for this once-a-year educational event. Whether you have practiced pain medicine or interventional pain management for years, if you are new to the discipline, or if you are in training—the ever-changing field of medicine, practice management, and rules and regulations associated with these specialties makes this an essential course for you. Sincerely, Laxmaiah Manchikanti, MD Chairman of the Board and Chief Executive Officer, ASIPP AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS2 ESSENTIALSIN PRACTICEMANAGEMENT INIPMCOMPREHENSIVEREVIEWCOURSEANDCOMPETENCYEXAMINATION CONTROLLEDSUBSTANCEMANAGEMENT: WHATYOUNEEDTOKNOWCOMPREHENSIVEREVIEWCOURSE ANDCOMPETENCYEXAMINATION OCTOBER 4-6, 2013 | DENVER, COLORADO AmericanSocietyof InterventionalPainPhysicians THE VOICE OF INTERVENTIONAL PAIN MANAGEMENT SINCE 1998 81 Lakeview Drive, Paducah, KY 42001 Phone: 270.554.9412 | Fax: 270.554-5394 E-Mail: asipp@asipp.org Web Site: www.asipp.org CHAIRMAN OF THE BOARD AND CHIEF EXECUTIVE OFFICER Laxmaiah Manchikanti, MD—Paducah, KY PRESIDENT Hans C. Hansen, MD—Conover, NC IMMEDIATE PAST PRESIDENT Frank J.E. Falco, MD—Newark, DE PRESIDENT-ELECT Ramsin M. Benyamin, MD—Bloomington, IL FIRST EXECUTIVE VICE PRESIDENT David L. Caraway, MD, PhD—Huntington, WV SECOND EXECUTIVE VICE PRESIDENT Aaron K. Calodney, MD— Tyler, TX VICE PRESIDENT STRATEGIC PLANNING Francis Riegler, MD—Malibu, CA SECRETARY Peter S. Staats, MD—Shrewsbury, NJ TREASURER David Bryce, MD—Middleton, WI LIFETIME DIRECTORS Cyrus E. Bakhit, MD—Roanoke, VA Laxmaiah Manchikanti, MD—Paducah, KY Vijay Singh, MD—Niagara, WI DIRECTORS AT LARGE Salahadin Abdi, MD—Houston, TX Mark V. Boswell, MD, PhD—Louisville, KY Harold Cordner, MD—Sebastian, FL Tim Deer, MD—Charleston, WV Sudhir Diwan, MD—New York, NY Haroon Hameed, MD—Blatimore, MD Mariam Hameed, MD—Boston, MA Joshua A Hirsch, MD—Boston, MA Alan Kaye, MD, PhD—River Ridge, LA Allan T. Parr, MD—Covington, LA Gabor B. Racz, MD—Lubbock, TX David M. Schultz, MD—Minneapolis, MN John R. Swicegood, MD—Fort Smith, AR Andrea M. Trescot, MD—Eagle River, AK DIRECTORS EMERITUS Standiford Helm II, MD—Laguna Hills, CA David S. Kloth, MD—Danbury, CT PAIN PHYSICIAN EDITOR-IN-CHIEF Alan David Kaye, MD, PhD—New Orleans, LA AMA DELEGATES Lee T. Snook, MD—Sacramento, CA Haroon Hameed, MD—Baltimore, MD STAFF Melinda Martin, Director of Operations Ray Lane, Director of Public Relations Holly Long, Coordinator of Editorial Services Vidyasagar Pampati, Statistician and Programmer Paula Reynolds Spear, Meeting Coordinator Tom Prigge, Multimedia Specialist Cindy Rogers, Administrative Assistant Summer Moffitt, Administrative Assistant GOVERNMENT AFFAIRS COUNSEL Senator Tim Hutchinson & Randi Hutchinson, Esq., Dickstein Shapiro, LLP, 1825 Eye Street NW Washington, DC 20006 202.420.3600 hutchinsont@dicksteinshapiro.com Jeff Mortier, Legislative Partner Ryan, Mackinnon, Vasapoli and Berzok, LLP 1634 Eye Street NW, Suite 1200 Washington, DC 20006 GENERAL COUNSEL Erin Brisbay McMahon JD, Wyatt, Tarrant & Combs, LLP, 250 West Main Street, Suite 1600 Lexington, KY 40507 859.288.7452 | emcmahon@wyattfirm.com
  3. 3. STATEMENT OF NEED These two-day comprehensive review courses are planned as a CME activity to prepare for competency certification or an in-depth review in areas of What You Need to Know in Controlled Substance Management and Essentials in Practice Management in IPM. This review course is based on the American Board of Interventional Pain Physicians’ specifications for competency certification examinations. This course will provide in-depth evaluation of the knowledge of the participants with extensive review of subject(s). As part of this comprehensive, in-depth, intense two-day review course, ASIPP will provide participants with online mateiral of the lectures. EDUCATIONAL OBJECTIVES/TARGET AUDIENCE The courses are intended to present interventional pain management specialists, nurses, and other healthcare providers an in-depth review of multiple areas of interventional pain management including What You Need to Know in Controlled Substance Management. Educational Objectives for What You Need to Know in Controlled Substance Management: • Review basic science and core concepts • Discuss pharmacology • Identify clinical use and effectiveness • Identify substance abuse • Discuss topics with documentation, regulatory issues, legal issues, and ethical issues Educational Objectives for Essentials in Practice Management in IPM: • Discuss documentation • Review practice management topics • Discuss coding and billing • Examine compliance issues OUTCOME Participants in the What You Need to Know in Controlled Substance Management Course should be able to apply the fundamental concepts of managing controlled substances in your practice, from pharmacology and the clinical uses to identifying abuse and the legal aspects of prescribing, for better outcomes and reduced side effects. Participants in the Essentials in Practice Management in IPM Course will learn to operate comprehensive interventional pain care centers more efficiently, so that patients will receive the best care available. AMERICANSWITH DISABILITIES ACT AND SPECIAL SERVICES Organizers fully comply with the legal requirements of the Americans with Disabilities Act and the rules and regulations thereof. If any participant in this educational activity is in need of accommodations, please contact the organizers at (270) 554‑9412 at least 10 days prior to the conference. ACCREDITATION STATEMENT This CME activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education thru the Joint Sponsorship of the Institute for Medical Studies (IMS) and the American Society of Interventional Pain Physicians. The Institute for Medical Studies is accredited by the ACCME to provide continuing medical education for physicians. CATEGORY I CREDIT The Institute for Medical Studies designates this educational activity for a maximum of 14 AMAPRACategory1Credits™ for Controlled SubstanceManagement and 14.25 AMAPRACategory1Credits™ forthe EssentialsinPracticeManagement. Physicians should only claim credit commensurate with the extent of their participation in the activity. RN, NP AND PA CREDIT Nurses may claim credit for activities approved for AMAPRACategory 1Credits™ in most states, for up to 14 AMAPRACategory1Credits™ for ControlledSubstanceManagement and 14.25 AMAPRACategory1 Credits™ fortheEssentialsinPracticeManagement. Nurse Practitioners:The American Academy of Nurse Practitioners (AANP) accepts14 AMAPRACategory1Credits™ for ControlledSubstance Management and 14.25 AMAPRACategory1Credits™ fortheEssentialsin PracticeManagement from organizations accredited by the ACCME. IMS is accredited to provide continuing medical education for physicians and will provide nurse practitioners who successfully complete each activity with a certificate of participation indicating that the activity was designated for the catagorycreditslistedabove. The American Academy of Physician Assistants (AAPA) accepts AMAPRA Category1Credits™ from organizations accredited by the ACCME.The provider of this program, the Institute for Medical Studies, is accredited by the ACCME and designates this educational activity for a maximum of 14 AMAPRACategory1Credits™ for ControlledSubstanceManagement and 14.25 AMAPRACategory1Credits™ fortheEssentialsinPractice Management. Physician assistants should only claim credit commensurate with the extent of their participation in the activity. CODING CREDIT ASIPP has applied for approval of the American Academy of Professional Coders for the appropriate Continuing Education Units. Granting of this approval in no way constitutes endorsement by the Academy of the program, content or any sponsors. There is no commercial support for this course. No duplication or distribution of materials, or recording of lectures associated. There is NO commercial support for this course. ACCOMMODATIONS THE WESTIN DENVER DOWNTOWN 1672 LAWRENCE STREET DENVER, CO 80202 (303) 572-9100 Located in renowned Lower Downtown Denver, we’re a stroll away from the 16th Street pedestrian mall, Denver Center for Performing Arts, Convention Center, museums, and entertainment. We’re also within walking distance of professional sports venues. Informthehotelthatyouare bookingforASIPP.Wehavesecuredagrouproomrateof $169.Reserverooms early—allunbooked roomswillbereleased onSeptember12,2013. AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS 3 ESSENTIALSIN PRACTICEMANAGEMENT INIPMCOMPREHENSIVEREVIEWCOURSEANDCOMPETENCYEXAMINATION CONTROLLEDSUBSTANCEMANAGEMENT: WHATYOUNEEDTOKNOWCOMPREHENSIVEREVIEWCOURSE ANDCOMPETENCYEXAMINATION OCTOBER 4-6, 2013 | DENVER, COLORADO
  4. 4. AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS4 CONTROLLEDSUBSTANCEMANAGEMENT: WHATYOUNEEDTOKNOWCOMPREHENSIVEREVIEWCOURSE ANDCOMPETENCYEXAMINATION OCTOBER 4-6, 2013 | DENVER, COLORADO Noduplicationordistributionofmaterials,orrecordingoflecturesassociatedwiththisconferenceispermitted withoutexpresswrittenconsentoftheAmericanSocietyofInterventionalPainPhysicians.Allrightsreserved. 7:00am–8:00am REGISTRATION AND BREAKFAST 8:00am–8:30am Introduction and Status of Drug Abuse Alan Kaye, MD, PhD 8:30am–9:30am A DEA Perspective of the Drug Abuse Epidemic Shane Pitts 9:30am–10:15am Comprehensive Assessment and Documentation of a Chronic Pain Patient Susan Blank, MD 10:15am–10:45am BREAK 10:45am–11:30am Application of Opioid Guidelines and Documentation Laxmaiah Manchikanti, MD 11:30am – 12:15pm Terminology, Mechanisms and Management of Abuse and Addictive Disorders Sanford Silverman, MD 12:15pm 1:15pm LUNCH (provided) 1:15pm–2:00pm Anatomy, Physiology, and Psychology of Chronic Pain Alan Kaye, MD, PhD 2:00pm–2:45pm Current Drug Therapy, Non-Opioid Drug Therapy, and Other Interventions Daniel Schwarz, MD 2:45pm–3:30pm Controlled Substance Pharmacology: Non-Opioids, Benzodizepines, Sedatives, and Hypnotics Sanford Silverman, MD 3:30pm–4:00pm BREAK 4:00pm–4:45pm Opioid Pharmacology, Interactions, and Side Effects Alan Kaye, MD, PhD 4:45pm–5:30pm Adherence Monitoring and Drug Testing Laxmaiah Manchikanti, MD 7:30am–8:30am REGISTRATION & CONTINENTAL BREAKFAST 8:30am–9:30am Dealing with a Difficult Patient: Demanding, Manipulative, and Seductive Daniel Schwarz, MD 9:30am–10:30am Critical Review of Effectiveness of Opioids in Chronic Pain Susan Blank, MD 10:30am–11:00am BREAK 11:00am–12:00am Preventing and Responding to Drug Investigations of Your Practice Jean Veilleux, JD 12:00 am–1:00pm Assessment and Management of Drug Dependency and Withdrawal in Patients and Health Care Team Sanford Silverman, MD 1:00pm–2:00pm LUNCH (provided) 2:00pm–3:00pm Office Detoxification Sanford Silverman, MD 3:00pm–3:30pm BREAK 3:30pm–5:00pm Ethics in Interventional Pain Management Gail Van Norman, MD EXAMINATION - WHATYOU NEEDTO KNOW IN CONTROLLED SUBSTANCE MANAGEMENT 7:00am BREAKFAST AND REGISTRATION 7:45am Test Instruction and Examination (You will have 2 hours to complete the 100 question examination) WHAT YOU NEED TO KNOW IN CONTROLLED SUBSTANCE MANAGEMENT FRIDAY OCTOBER 4, 2013 WHAT YOU NEED TO KNOW IN CONTROLLED SUBSTANCE MANAGEMENT SATURDAY OCTOBER 5, 2013 WHAT YOU NEED TO KNOW IN CONTROLLED SUBSTANCE MANAGEMENT SUNDAY OCTOBER 6, 2013
  5. 5. AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS 5 ESSENTIALSIN PRACTICEMANAGEMENT INIPMCOMPREHENSIVEREVIEWCOURSEANDCOMPETENCYEXAMINATION OCTOBER 4-6, 2013 | DENVER, COLORADO 7:00am–8:00am REGISTRATION & CONTINENTAL BREAKFAST 8:00am–8:30am Introduction Laxmaiah Manchikanti, MD 8:30am–9:30am An Introduction to Fraud, Abuse, Compliance, and Defense Vicki Myckowiak, JD 9:30am–10:30am Documentation for Evaluation and Management Services Marvel Hammer, RN, CPC 10:30am–10:45am BREAK 10:45am–11:45am Coding for Evaluation and Management Services Marvel Hammer, RN, CPC 11:45am 12:45pm LUNCH (provided) 12:45pm–1:45pm Anatomical Correlation of CPT Coding for IPM Procedures Marvel Hammer, RN, CPC 1:45pm–2:45pm Documentation, Coding and Billing for IPM Procedures Marvel Hammer, RN, CPC 2:45pm–3:45pm ASC Versus In-Office Coding and Billing Judith Blaszczyk, RN, CPC 3:45pm–4:00pm BREAK 4:00pm–5:00pm Documentation and Coding: Physical Therapy and Behavioral and Other Sciences Marvel Hammer, RN, CPC 7:00am–8:00am REGISTRATION & BREAKFAST 8:00am–8:45am Coverage Policies, Reviews, and Appeals Judith Blaszczyk, RN, CPC 8:45am – 9:30am OIG Compliance; Good, Bad and Ugly Vicki Myckowiak, JD 9:30am– 10:15am STARK Jean Veilleux, JD 10:15am-10:45am BREAK 10:45am–11:30am HIPAA; Good, Bad and Ugly Vicki Myckowiak, JD 11:30 am–12:15pm Developing an Interventional Pain Practice: Setting it up for Success Michael Brown 12:15pm–1:15pm LUNCH (provided) 1:15pm–2:00pm Employment Law Basics Every Practitioner Needs to Know Judith Holmes, JD 2:00pm–2:45pm Financial Management: Best Practices in Revenue Cycle Management, Maximiz- ing Patient Collections, Surviving in Turbulent Times Michael Brown 2:45pm–3:30pm Risk Management: Employment Law Compliance Issues Judith Holmes, JD 3:30pm-4:00pm BREAK 4:00pm–4:45pm Handling Difficult Employees Judith Holmes, JD EXAMINATION - ESSENTIALS IN PRACTICE MANAGEMENT IN IPM 7:00am BREAKFAST AND REGISTRATION 7:45am Test Instruction and Examination (You will have 2 hours to complete the 100 question examination) ESSENTIALS IN PRACTICE MANAGEMENT IN IPM FRIDAY OCTOBER 4, 2013 ESSENTIALS IN PRACTICE MANAGEMENT IN IPM SUNDAY OCTOBER 6, 2013 ESSENTIALS IN PRACTICE MANAGEMENT IN IPM SATURDAY OCTOBER 5, 2013
  6. 6. PAYMENT METHOD (Please check one): m MASTERCARD m VISA m AMERICAN EXPRESS m DISCOVER ______________________________________________________________________________________ CREDIT CARD NUMBER EXPIRATION DATE SECURITY CODE ______________________________________________________________________________________ NAME ON CARD m CHECK CHECK NUMBER _____________________________ m ENCLOSED (Payable to ABIPP) (Your application will not be processed if payment does not accompany registration form) _________________________________________________________________________________________ SIGNATURE OF APPLICANT Please type or print your information clearly ________________________________________________________________________________________________________________________________________________ NAME (First) (Middle Initial) (Last) ______________________________________________________________________ ORGANIZATION ______________________________________________________________________ ORGANIZATION ADDRESS ______________________________________________________________________ CITY STATE ZIP ______________________________________________________________________ PHONE FAX ______________________________________________________________________ E-MAIL PERSONAL DATA: (for statistical purposes only) DATE OF BIRTH ______/______/______ m MALE m FEMALE MEDICAL DEGREE: m MD m DO m PhD m Other (specify) _______________________ I AM CURRENTLY CERTIFIED BY THE FOLLOWING BOARD(S): m m American Board of Anesthesiology m American Board of Psychiatry and Neurology m American Board of Physical Medicine & Rehabilitation m ABA Subspecialty in Pain Medicine m Fellow of Interventional Pain Practice (FIPP) m American Board of Interventional Pain Physicians (ABIPP) m Other ABMS Primary Board(s) ________________________________________________________ m Other) _____________________________________________ SPECIALTY DESIGNATION: m 09 IPM m 72 Pain Medicine m Anesthesiology m Psychiatry m Neurology m Other ________________________ What percentage of your clinical practice is in the field of Interventional Pain Management: m 0% m 1–49% m 50–100% PRIMARY PROFESSIONAL PRACTICE SETTING (please check all that apply): m Ambulatory surgery m Hospital m Office Practice m Academic m University m Administrative m Military m VA m Other STATE LICENSE: State ____________________________________________ License Number _____________________________________________________________ PREFERRED MAILING ADDRESS m Organization m Home RETURN COMPLETED FORMTO: ASIPP, 81 Lakeview Drive, Paducah, KY 42001 or Fax to (270) 554-5394 CANCELLATION POLICY: ASIPP reserves the right to cancel this course upon reasonable notice and will assume no financial obligation to registrants for cancellation for reasons beyond its control. Registration fees will be refunded however, costs incurred by the registrants, such as airline or hotel fees or penalties, are the responsibility of the registrants. ASIPP requires a 30-day notice of cancellation. Cancellations must be submitted in writing by September 4, 2013. An administrative fee of $200 will be assessed. Cancellations after September 4, 2013 but prior to September 25, 2013, will forfeit 50% of their registration fee. No cancellations accepted after September 25, 2013. Refunds will be sent after the conclusion of the meeting Foryourconvenienceandfasterregistration,registeronlineat www.asipp.org/meetings.htm REGISTRATION FOR PHYSICIANS AME RICANBOARDO F INTERVENTION ALPAINPHYSICI ANS ABIPP PHYSICIAN WORKSHOP REGISTRATION INFORMATION REGISTRATION FEES Review Course in What You Need to Know in Controlled Substance Management m $700 (Member) m $900 (Non-Member) Competency Exam in What You Need to Know in Controlled Substance Management m $600 Review Course in Essentials in Practice Management in IPM m $700 (Member) m $900 (Non-Member) Competency Exam in Essentials in Practice Management in IPM m $600 Fellow Discount m 50% Discount ______________________________________________________________________ HOME ADDRESS ______________________________________________________________________ CITY STATE ZIP ______________________________________________________________________ PHONE FAX ______________________________________________________________________ E-MAIL AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS6 ESSENTIALSIN PRACTICEMANAGEMENT INIPMCOMPREHENSIVEREVIEWCOURSEANDCOMPETENCYEXAMINATION CONTROLLEDSUBSTANCEMANAGEMENT: WHATYOUNEEDTOKNOWCOMPREHENSIVEREVIEWCOURSE ANDCOMPETENCYEXAMINATION OCTOBER 4-6, 2013 | DENVER, COLORADO
  7. 7. PAYMENT METHOD (Please check one): m MASTERCARD m VISA m AMERICAN EXPRESS m DISCOVER ______________________________________________________________________________________ CREDIT CARD NUMBER EXPIRATION DATE SECURITY CODE ______________________________________________________________________________________ NAME ON CARD m CHECK CHECK NUMBER _____________________________ m ENCLOSED (Payable to ABIPP) (Your application will not be processed if payment does not accompany registration form) _________________________________________________________________________________________ SIGNATURE OF APPLICANT Please type or print your information clearly ________________________________________________________________________________________________________________________________________________ NAME (First) (Middle Initial) (Last) ______________________________________________________________________ ORGANIZATION ______________________________________________________________________ ORGANIZATION ADDRESS ______________________________________________________________________ CITY STATE ZIP ______________________________________________________________________ PHONE FAX ______________________________________________________________________ E-MAIL PERSONAL DATA: (for statistical purposes only) DATE OF BIRTH ______/______/______ m MALE m FEMALE HIGHEST DEGREE EARNED: ______________________________________________________________________________ CERTIFICATIONS: m JD m MBA m MA m CPA m CPC m CPE m PA m NP m CRNA m RN m RT m ST m Other (specify) ________________ PROFESSIONAL QUALIFICATIONS/EXPERIENCE IN THE FIELD: m Coding ___ years m Billing ___ years m Compliance ___ years m Practice Management ___ years PREFERRED MAILING ADDRESS m Organization m Home RETURN COMPLETED FORM TO: ASIPP, 81 Lakeview Drive, Paducah, KY 42001 or Fax to (270) 554-5394 CANCELLATION POLICY: ASIPP reserves the right to cancel this course upon reasonable notice and will assume no financial obligation to registrants for cancellation for reasons beyond its control. Registration fees will be refunded however, costs incurred by the registrants, such as airline or hotel fees or penalties, are the responsibility of the registrants. ASIPP requires a 30-day notice of cancellation. Cancellations must be submitted in writing by September 4, 2013. An administrative fee of $200 will be assessed. Cancellations after September 4, 2013 but prior to September 25, 2013, will forfeit 50% of their registration fee. No cancellations accepted after September 25, 2013. Refunds will be sent after the conclusion of the meeting Foryourconvenienceandfasterregistration,registeronlineat www.asipp.org/meetings.htm REGISTRATION FOR NON-PHYSICIANS NON-PHYSICIAN WORKSHOP REGISTRATION INFORMATION REGISTRATION FEES Review Course in What You Need to Know in Controlled Substance Management m $500 (Member) m $600 (Non-Member) Competency Exam in What You Need to Know in Controlled Substance Management m $500 Review Course in Essentials in Practice Management in IPM m $500 (Member) m $600 (Non-Member) Competency Exam in Essentials in Practice Management in IPM m $500 ______________________________________________________________________ HOME ADDRESS ______________________________________________________________________ CITY STATE ZIP ______________________________________________________________________ PHONE FAX ______________________________________________________________________ E-MAIL AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS 7 ESSENTIALSIN PRACTICEMANAGEMENT INIPMCOMPREHENSIVEREVIEWCOURSEANDCOMPETENCYEXAMINATION CONTROLLEDSUBSTANCEMANAGEMENT: WHATYOUNEEDTOKNOWCOMPREHENSIVEREVIEWCOURSE ANDCOMPETENCYEXAMINATION OCTOBER 4-6, 2013 | DENVER, COLORADO
  8. 8. PRSRTSTD U.S.POSTAGE PAID PADUCAH,KY PERMIT#44 AmericanSocietyof InterventionalPainPhysicians 81LakeviewDrive,Paducah,KY42001 ESSENTIALSIN PRACTICEMANAGEMENTINIPMCOMPREHENSIVEREVIEWCOURSE ANDCOMPETENCYEXAMINATION UPTO14.25AMAPRACATEGORY1CREDITS™ CONTROLLEDSUBSTANCE MANAGEMENTWHATYOUNEEDTOKNOWCOMPREHENSIVEREVIEWCOURSE ANDCOMPETENCYEXAMINATION UPTO14AMAPRACATEGORY1CREDITS™ OCTOBER4-6,2013|DENVER,COLORADO HOTEL&REVIEWCOURSELOCATION: TheWestinDenverDowntown,1672LawrenceStreet,Denver,CO80202|1-303-572-9100 SPECIALDISCOUNTS: •$100eachforInterventionalTechniquesinChronicSpinalPainandChronicNon-SpinalPain •10%offFoundations,ClinicalAspects,and/orBoardReviewSelf-Assessment •20%offEssentialsofPracticeManagement:Billing,Coding, andComplianceinInterventionalPainManagement •50%OffMeetingFeetoFellows&Residents •SpecialroomratesthoughSeptember12,2013

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