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Executive Leadership Certificate Program or Physician Leadership in the Changing Health Care Environment

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  • 1. Registration Form (internal use: 40500-003099) To register, complete the registration form and mail it to Massachusetts Medical Society, P.O. Box 9155, Waltham, MA 02454-9155. Or register by calling 800.843.6356 or faxing 781.893.0413. Payment is due at the time of registration. Cancellations received in writing on or before September 13, 2013, will be refunded, less a 20% administrative charge. No refunds can be made after this date. 800.843.6356 www.massmed.org//mmsleadership September 20 and 21, 2013 (at Brandeis) January 24 and 25, 2014 (at MMS) May 9 and 10, 2014 (at Brandeis) Physician Leadership in the Changing Health Care Environment A jointly sponsored CME and certificate program with the Heller School for Social Policy and Management, Brandeis University. Please check: [ ] MMS Member [ ] Nonmember Membership Number: ___ ___ ___ ___ ___ ___ ___ First Name:________________________________________________________________ Middle initial: __________________ Last Name:_________________________________________________________________________________ [ ] MD [ ] other EMail:_______________________________________________________________________________________________________ Title:_______________________________________________________________________________________________________ Organization:_______________________________________________________________________________________________ Address:____________________________________________________________________________________________________ City: ____________________________________________________ State: ___________________ Zip Code:_______________ phone: __________________________________________________ Fax:_______________________________________________ Registration Fee MMS Member NonMember Physician $2500 $5000 (or $2600)* [ ] *Yes, I’d like to join the MMS for $100 and attend this program for $2500. District Dues may Apply. [ ] Enclosed is my check payable to the Massachusetts Medical Society for $ ________________________. [ ] Please bill my credit card for $ ________________________. [ ] Amex [ ] Visa [ ] MasterCard Card Number: ______________________________________________________________________________________________ Expiration Date:_____________________________________________________________________________________________ Cardholder’s Signature:____________________________________________________________________________________ Join the MMS through December 31, 2014, for $100 and attend this program for $2,500. This offer is available only to first-time MMS members and is valid until September 20, 2013. Additional local district medical dues may apply. For details, please call 800.322.2303, ext. 7311. 14PPL