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HCPro Boot Camp -- Course Registration Form

Select your course:

Certified Coder Boot Camp® --Original Version Certified Coder Boot Camp® --Inpatient Version Medicare Boot Camp® --Hospital Version Medicare Boot Camp® --Physician Services Version Medicare Boot Camp® --Long-Term Care Version

Please write in the date and location of the program that you would like attend: _________________________________________ Name: Organization: Address: City: Phone: _________________________________________________ Nickname: ________________________________ ______________________________________________ Title: ____________________________________ ________________________________________________________________________________________ _____________________________________________ State: ____________ Zip: ____________________ _______________________ Fax: ___________________ E-Mail: _________________________________

Are you planning on taking the CPC Exam? Yes No What is your education level? ________________________________________________________________________________ What type of facility are you affiliated with: Hospital Physician practice System Managed Care Long Term Care Other ____________________________ If you are affiliated with a facility, what is the bed size of your facility? Less than 50 50--200 Greater than 200

If you are affiliated with a Physician Practice, what size is your practice? _________ What is your practice specialty? _______________

Are you now or ever been employed as a coder? Yes No Payment Type: A check for my course fee is enclosed (make payable to "HCPro"), or Charge my course fee to (circle one): Visa MasterCard Name on Card: ____________________________________ Signature:

American Express

Cardholder Street Address: _______________________________________________________ Zip: _______________________ Card Number: _________________________________________________ Exp. Date: ________________________________

Please print this form and mail or fax the completed form to: HCPro, Inc. 200 Hoods Lane Marblehead, MA 01945 Phone: (800) 780-0584 Fax: (800) 738-1553

Upon receipt of this form and your course fee, we will send confirmation of your registration, including hotel information, information on any manuals/texts required for class and, for the Certified Coder Boot Camp® ­ Original Version, information on registering for the certification exam (this information is also available on our web site at www.hcprobootcamps.com). All cancellations must be made in writing. Cancellations received within 3 days of the date HCPro, Inc. receives the registration are eligible for a full refund. Written cancellations received between 4 days after the date HCPro, Inc. receives the registration and 15 days prior to first day of class are eligible for a refund, less a $200 cancellation fee. Written cancellations received 14 days prior to the first day of class are not eligible for a refund, but are eligible for payment transfer (credit) to another Certified Coder Boot Camp® or Medicare Boot Camp® (less a $200 transfer fee). The credit is valid for up to 12 months from date of the cancelled class. Participant(s) who do not cancel in writing will be considered as "no shows" and will not be eligible for refunds/credits. We recommend against making travel arrangements until after we have confirmed your course registration. Registrations are accepted in the order received. Classes sometimes sell out before the registration deadline.

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The registration fees for our courses are subject to change. Check www.hcprobootcamps.com or call 800/780-0584 for our current course fees. We update this form whenever any course fee is changed. In the event that we receive a registration using an out-of-date form, we will contact you before processing your payment.

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