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MGMA Cardiovascular Specialties Preconference


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MGMA Cardiovascular Specialties Preconference

  1. 1. Registration FormMGMA-ACMPE ID:Last name: First name: MI: Suffix/credentials: (eg.: MD, CMPE, FACMPE)Preferred name on badge (e.g., Joe instead of Joseph): Title: Clinic or organization: Dept.:Mailing address: City/State/ZIP:m Billing address, same as Mailing addressBilling address: City/State/ZIP:Telephone: Mobile:Email: CC Email:Would you like to receive conference updates via text message to your mobile device while on-site? m Y m NPhysician NPI#:Emergency contact information Name: E-mail: Daytime telephone: Evening telephone:Dietary restrictions: m Y m N If yes, please explain:ADA or special requirements: m Y m N If yes, please explain:Demographic InformationNumber of full-time equivalent physicians in your practice:Please select what type of organization you work for? (Select one) m Medical practice m Academic practice m Service organization m Other healthcare delivery organization (If you selected other healthcare delivery organization, please select all that apply) m Ancillary Service Provider m Freestanding Ambulatory Surgery Center m Health Maintenance Organization m Hospital m Independent Practice Assn. m Integrated Health System m Long-term/Skilled/Nurse Facility m Management Service Organization m Physician Hospital Organization m Physician Practice Management Company m Preferred Provider Organization m Other Healthcare Delivery Organization:Last name: Telephone: 1
  2. 2. Registration FormDemographic Information (continued)Please select the physician specialty in which you work: (Select one) m Single specialty m Multispecialty (Select all that apply) m Allergy/Immunology m Anesthesia m Cardiology m Critical care m Dentistry m Dermatology m Emergency medicine m Endocrinology/Metabolism m Family practice m Gastroenterology m Genetics m Geriatrics m Hospital medicine m Infectious disease m Internal medicine m Nephrology m Neurology m OB/GYN m Occupational medicine m Oncology/Hematology m Ophthalmology m Orthopedics m Otorhinolaryngology m Pain management m Pathology m Pediatrics m Physiatry m Physical therapy m Podiatry m Psychiatry m Pulmonary medicine m Radiology m Rheumatology m Surgery m Urgent care m Urology m Other specialty:Do you plan on attending the academic practice track during the conference? m Y m NYear you became an MGMA-ACMPE member:I’m attending the following for the first-time: (Please select all that apply) m MGMA Annual Conference m MGMA Cardiovascular Specialties Preconference m MGMA Gastroenterology Preconference m MGMA Orthopedic Preconference m MGMA Pathology Preconference m MGMA Surgical Practices PreconferenceConference Host Program (Response required by Sept. 21, 2012) Is this your first time attending the conference or need a refresher? m Y m N If so, please select all that apply: I am interested in being paired with an experienced conference attendee who will help me navigate the conference before and during the event. (This option is no longer available as of Sept. 21, 2012) I am interested in attending a webinar prior to arrival in San Antonio to help me navigate the conference. (This option is no longer available as of Oct. 1, 2012)How would you like to receive your information on Exhibit Hall give-aways and product/service solutions? m Both direct mail and email m Direct mail only m Email only m I do not want to receive these communicationsPlease identify the primary source that prompted you to register: m Brochure m Direct mail m E-mail m Handout at an MGMA education event m Magazine article m Print ad m Referral from a friend or colleague m Referral from an MGMA-ACMPE representative m Social media (Facebook, Twitter, LinkedIn) m Website m Vendor referral: (please provide name of vendor) m Other:Last name: Telephone: 2
  3. 3. Registration Fees Postmarked on Postmarked or before Friday, Sept. 21 after Friday, Sept. 21 Category Total Using MGMA group housing* Standard rate* Standard rate* MGMA-ACMPE member $875 $1025 $1075 $ National MGMA-ACMPE affiliate $975 $1125 $1175 $ New national MGMA-ACMPE member $1125 $1275 $1325 $ (includes MGMA-ACMPE membership and registration fee) MGMA-ACMPE nonmember $1225 $1375 $1425 $ m heck here if you are the first person registering from your organization as part of a group. Your group discount code will be sent in your individual C registration confirmation and must accompany all subsequent registrations in your group. m heck here if you are registering as part of a group and have a group discount code. C Enter group discount code: (This code can be found on the first attendee’s registration confirmation.) Group registration pricing: 1st paid person in group – full price 4th – 6th registrants of the group receive — $125 off 2nd and 3rd individuals in group receive — $100 off 7+ registrants of the group receive — $150 off Group discounts do not apply to the following registration categories: Spouse, Faculty, Student and One-day conference rates. Spouse $205 $305 $ If registering spouse (include spouse name) Last name: First name: Faculty (must be employed as a full time college or university faculty $200 $ and provide verification of status) Student (must be enrolled as a full time student or resident and provide $100 $ verification of status) One-day conference m Sunday only $200 $ One-day conference m Monday only m Tuesday only $600 $ One-day conference m Wednesday only $275 $ Subtotal page 3 $Promotion code:Last name: Telephone: 3
  4. 4. Registration Fees (continued) Activities (preregistration required, no additional fees) Sunday, Oct. 21 (3:00 pm) m Academic practice networking reception m Section receptions: Eastern, Midwest, Southern, Western N/A m MGMA-ACMPE Newcomer, Student, Faculty and Alumni reception - Name of college/university: Monday, Oct. 22 (11:30 am) m Ambulatory Surgery luncheon m Cardiovascular Specialties luncheon m Gastroenterology luncheon m Emergency Medicine luncheon m Hospitalists luncheon m Medical Imaging/Radiology luncheon m Nephrology luncheon N/A m Neurosciences luncheon m Obstetrics and Gynecology luncheon m Oncology/Hematology luncheon m Ophthalmology luncheon m Orthopedic luncheon m Pain Management luncheon m Primary Care luncheon m Surgical Practice luncheon m Uniformed Services luncheon m Urology luncheon Tuesday, Oct. 23 (9:30-11:30 am) Primary Care Executive Circles. (These Executive Circles are full and are no longer available for registration). N/A Tuesday, Oct. 23 (1:45-4:45 pm) Orthopedic Executive Circles. (These Executive Circles are full and are no longer available for registration). Postmarked on or before Postmarked after Friday, Sept. 21 Friday, Sept. 21 Preconferences (preregistration required) Total Member Nonmember Member Nonmember Saturday, Oct. 20 and Sunday, Oct. 21 (additional fees required) PRE101 MGMA Pathology Preconference $425 $625 $525 $725 $ (1-1/2 days) PRE102 MGMA Cardiovascular Specialties $399 $499 $599 $699 $ Preconference (2 half days) PRE110 Mastering the Revenue Cycle: Avoid $399 $499 $599 $699 $ Potholes in the Road to Getting Paid (2 half days) PRE111 Train Your Office for Success: Mastering $399 $499 $599 $699 $ Patient Flow (2 half days) Sunday, Oct. 21 (additional fees required) PRE103 MGMA Gastroenterology $275 $475 $375 $575 $ Preconference (1/2 day) PRE104 MGMA Orthopedic Preconference $275 $475 $375 $575 $ (1/2 day) PRE105 MGMA Surgical Practices Preconference $275 $475 $375 $575 $ (1/2 day) Subtotal page 4 $Last name: Telephone: 4
  5. 5. Registration Fees (continued) ACMPE Events (preregistration required) Saturday, Oct. 20 (additional fees required) PRE106 ACMPE Pathway to Certification: Earning the CMPE Designation $185 $ PRE107 ACMPE Pathway to Fellowship: Earning the FACMPE Designation $95 $ PRE106/PRE107 ACMPE Package Discount: Pathway to Earning the CMPE and FACMPE Designations $245 $ Sunday, Oct. 21 (additional fees required) PRE108 Board certification essay examination (registration deadline: Oct. 5) $165 $ PRE109 Board certification objective examination (registration deadline: Oct. 5) $165 $ Tuesday, Oct. 24 ACMPE business meeting luncheon and Fellows Convocation (11:30 am) Open to MGMA-ACMPE members, students, faculty and anyone interested in learning more about attaining ACMPE Qty: N/A board certification and Fellowship. No additional fee; space is limited and preregistration is required. ACMPE Fellows Dinner (7:00-10:00 pm) The Fellows Dinner is a private event for Fellows in the American College of Medical Practice Executives and their guests. ACMPE Fellows may purchase up to three (3) tickets for the event. All tickets must be purchased by an ACMPE Fellow. If you would like to purchase more than three (3) Fellows Dinner $70 tickets, please proceed with booking your allowed tickets through the standard registration process. For your $ Qty: additional tickets, contact with the subject line of: Fellow Dinner tickets. In your messaging, please include the following information: all guest names for requested and purchased tickets, along with reason for needing more than three (3) tickets. New Fellows: Please do not register. MGMA-ACMPE will provide registration information for you at a later date. Additional Registration Options Conference Audio Package Interested in receiving all audio recordings from the MGMA 2012 Annual Conference? $219 $ Sign up now to receive them at a reduced rate. Subtotal page 5 $ Total $Last name: Telephone: 5
  6. 6. Registration Fees (continued)We will send conference confirmations via email five to seven business days after processing. Hotel confirmations will besent in a separate e-mail. If you do not receive a confirmation, please call 866.229.3691 or e-mail be aware that if adding MGMA-ACMPE membership to your registration, processing may take up to three businessdays. Member rates are a privilege of membership. To qualify for member rates, you must be a member or join at the time ofreregistration. For additional information on registration categories, visit If your registration category isnot listed on this registration form, please contact MGMA-ACMPE at 877.275.6462, ext. 1888.During the MGMA 2012 Annual Conference, MGMA-ACMPE representatives may take photographs or video recordingsof conference attendees, and MGMA-ACMPE may use these materials for its editorial or marketing purposes. Conferenceattendees acknowledge that their image, likeness or voice may appear in these materials. By attending the MGMA 2012Annual Conference, attendees consent to MGMA-ACMPE’s use of their image, likeness or voice for MGMA-ACMPE’s editorialor marketing purposes in connection with any materials in which attendees appear.Register online: make a copy of all registration pages for your records. MGMA-ACMPE and Experient are not responsible forregistrations not received. Fax or mail completed registration forms with your check made payable to MGMA-ACMPE to:Mail: MGMA-ACMPE Registration Center Fax: 301.694.5124, credit cards only PO Box 714317 Charge my credit card: VISA MasterCard American Express Columbus, OH 43271-4317 Card number: Exp. date: Cardholder’s name: Cardholder’s signature: Date:Faxed registration will close on Monday, Oct. 15 and will not be accepted after that date.Last name: Telephone: 6