Course registration form

(1)

1: PLEASE cOMPLETE THE FOLLOWING

Name of Registrant

Title

Name of Organization

Mailing Address

City

State

Zip

Phone ( )

Fax ( )

E-mail

Train for ComplianCe

Course registration form

Please return your application and full payment by: Fax 858-228-1743. Please make checks payable to Train for Compliance. Or mail this form with correct enrollment fee (U.S. funds) to: TfC Registrar, 4676 Commercial St. SE #127, Salem, OR 97302-1902.

For more information: Call 888-596-0933 or send e-mail to [email protected] or visit www.TrainforCompliance.com.

Please enclose payment with your registration and return it to the conference registrar at the address below, or fax

your credit card payment to 858-228-1743.

❏

Check/money order enclosed (make checks payable to Train for Compliance)

❏

Credit card:

❏

American Express

❏

Visa

❏

MasterCard

Account Number:

Expiration: /

Name of Cardholder:

Signature of Cardholder:

3: PAYMENT OPTIONS

Please complete the following pages, selecting the courses you would like to register for.

Once completed, total your registration fee and input here: $

If you have a registration which code offers an adjusted price rate, please use that price in the column next to the

cours-es and provide that adjusted total on the line above. Please input your optional registration code here:

2: REGISTRATION PROcESS

(2)

cOURSE REGISTRATION - TRAIN FOR HEALTHcARE cOMPLIANcE cOURSES

Train for ComplianCe

Course registration form

$_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______ $_______

TOTAL: $ _______

10000. HEALTH cARE cOMPLIANcE BASIc TRAINING cOURSES

10001. BASIC GENERAl COMPlIANCE PROGRAM OVERVIEw - $95 10002. BASIC wRITTEN COMPlIANCE GUIdANCE - $95

10003. BASIC FRAUd ANd ABUSE IN HEAlTH CARE - $95 10004. SUBPOENAS, AUdITS, ANd SEARCH wARRANTS - $95 10005. INTROdUCTION TO ClAIMS PROCESSING COMPlIANCE - $95

10100. HEALTH cARE cOMPLIANcE ROLE-BASEd TRAINING cOURSES

10101. COMPlIANCE OFFICER: INTROdUCTION TO dUTIES ANd RESPONSIBIlITIES - $95 10102. COMPlIANCE OFFICER: MANAGEMENT OF HOTlINE/COMPlAINTS - $95

10103. COMPlIANCE OFFICER: RElATIONSHIP wITH lEGAl COUNSEl, HRM ANd FINANCIAl MANAGEMENT - $95 10104. SENIOR MANAGEMENT ANd CORPORATE GOVERNANCE - $95

10105. HEAlTHCARE CORPORATE GOVERNANCE: EFFECTIVE USE OF AUdIT COMMITTEES - $95

10200. HEALTH cARE cOMPLIANcE AdvANcEd TRAINING cOURSES

10201. AdVANCEd dEVElOPMENT ANd IMPlEMENTATION MEdICAl dIRECTOR/AdVISOR AGREEMENTS ANd SERVICES - $95 10202. AdVANCEd HANdlING OF OVERPAyMENTS ANd REFUNdS - $95

10203. AdVANCEd lEASING ANd RENTAl AGREEMENTS FOR HOSPITAlS - $95 10204. AdVANCEd SANCTIONS SCREENING - $95

10205. STARk FOR THE HOSPITAl AdMINISTRATOR - $95 10206. STARk FOR THE ClINIC AdMINISTRATOR - $95

10207. EMERGENCy MEdICAl TREATMENT ANd ACTIVE lABOR ACT (EMTAlA) - $95

10208. AdVANCEd dEVElOPMENT ANd IMPlEMENTATION OF PHySICIAN RECRUITMENT AGREEMENTS - $95

10300. HEALTH cARE cOMPLIANcE AdvANcEd TRAINING MINI MOdULES

10301. THE 72 HOUR PAyMENT wINdOw - $95 10302. PATH RUlES - $95

10303. "INCIdENT TO" BIllING - $95

10304. TRANSFER ANd dISCHARGE REqUIREMENTS - $95 10305. MEdICARE SECONdARy PAyORS - HOSPITAlS - $95 10306. AdVANCEd BENEFICIARy NOTICE (ABN) - $95 10308. SPECIAlIST REFERRAlS ANd CONSUlTATIONS - $95 10309. wAIVERS OF CO-PAyMENTS ANd dEdUCTIBlES - $95

(3)

cOURSE REGISTRATION - TRAIN FOR HIPAA cOURSES

Train for ComplianCe

Course registration form

20000. BASIc cURRIcULUM

❏ 20001. THE BASICS OF HEAlTHCARE PRIVACy, dATA SECURITy ANd HIPAA - $95 ❏ 20002. BASIC PRIVACy OF HEAlTH INFORMATION TRAINING I: CONFIdENTIAlITy - $95

❏ 20003. BASIC PRIVACy OF HEAlTH INFORMATION TRAINING II: PATIENT RIGHTS ANd AdMINISTRATIVE REqUIREMENTS - $95 ❏ 20004. BASIC HEAlTH INFORMATION SECURITy TRAINING - $95

20100. AdvANcEd TRAINING cOURSES

❏

20101. AdVANCEd HIPAA POlICy ANd PROCEdURE dEVElOPMENT - $95

❏

20102. AdVANCEd HIPAA BUSINESS ASSOCIATE RElATIONSHIPS - $95

❏

20103. AdVANCEd HIPAA MEdICAl RESEARCH COMPlIANCE - $95

❏

20104. AdVANCEd HIPAA COMPlIANCE FOR THE FINANCIAl SECTOR - $95

❏

20105. AdVANCEd HIPAA COMPlIANCE FOR IPAS - $95

20200. HIPAA TRANSAcTIONS ANd cOdE SETS TRAINING cOURSES

❏

20201. INTROdUCTION TO EdI ANd TRANSACTION COdE SET STANdARdS - $95

❏

20202. REGARdING HIPAA IMPlEMENTATION GUIdES: ANSI X12 STANdARdS I - $95

❏

20203. REGARdING HIPAA IMPlEMENTATION GUIdES: ANSI X12 STANdARdS II - $95

❏

20204. INTROdUCTION TO EdI ENVElOPES - $95

❏

20205. INTROdUCTION TO FINANCIAl EdI - $95

❏

20206. EXERCISE: BUIldING A SAMPlE 837 PROFESSIONAl HEAlTH CARE ClAIM - $95

❏

20207. EXERCISE: BUIldING A SAMPlE 835 HEAlTH CARE ClAIM PAyMENT/AdVICE - $95

❏

20208. EdI ACkNOwlEdGEMENTS - $95

❏

20209. HIPAA GUIdE CHANGE PROCESS, TESTING, ANd SECURITy - $95

20400. EMPLOYER TRAINING cOURSES

❏

20401. AdVANCEd HIPAA FOR EMPlOyERS - $95

❏

20402. ROlE-BASEd: HIPAA PRIVACy ANd SECURITy TRAINING FOR EMPlOyER CAll CENTERS - $95

20500. HEALTH PLAN TRAINING cOURSES

❏

20501. AdVANCEd HIPAA COMPlIANCE FOR HEAlTH PlANS - $95

❏

20502. HIPAA PRIVACy ANd SECURITy TRAINING FOR HEAlTH PlAN CAll CENTERS - $95

20600. HOSPITAL ANd HEALTH SYSTEM ROLE-BASEd cOURSES

❏

20601. ROlE-BASEd: HIPAA PRIVACy ANd SECURITy TRAINING FOR THE HOSPITAl MEdICAl STAFF - $95

❏

20602. ROlE-BASEd: HIPAA PRIVACy ANd SECURITy TRAINING FOR THE PATIENT-CARE wORkFORCE - $95

❏

20603. ROlE-BASEd: HIPAA PRIVACy ANd SECURITy TRAINING FOR REGISTRATION ANd AdMITTING STAFF - $95

❏

20604. ROlE-BASEd: HIPAA PRIVACy ANd SECURITy TRAINING FOR ClINICAl SUPPORT STAFF - $95

❏

20605. ROlE-BASEd: HIPAA PRIVACy ANd SECURITy TRAINING FOR THE ANCIllARy SERVICE PROVIdERS - $95

❏

20606. ROlE-BASEd: HIPAA PRIVACy ANd SECURITy TRAINING FOR CONTRACTING STAFF - $95

❏

20607. ROlE-BASEd: HIPAA PRIVACy ANd SECURITy TRAINING FOR PATIENT ACCOUNTING STAFF - $95

❏

20608. ROlE-BASEd: HIPAA PRIVACy ANd SECURITy TRAINING FOR HUMAN RESOURCES STAFF - $95

$ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______

(4)

Train for ComplianCe

Course registration form

cOURSE REGISTRATION - TRAIN FOR HIPAA cOURSES, cONT.

20700. PHYSIcIAN, IPA ANd MEdIcAL GROUP ROLE-BASEd cOURSES

❏

20701. ROlE-BASEd: HIPAA PRIVACy ANd SECURITy TRAINING FOR PHySICIANS - $95

❏

20702. ROlE-BASEd: HIPAA PRIVACy ANd SECURITy TRAINING FOR PHySICIAN dIRECT CARE STAFF - $95

❏

20703. ROlE-BASEd: HIPAA PRIVACy ANd SECURITy TRAINING FOR PHySICIAN FRONT OFFICE STAFF - $95

❏

20704. ROlE-BASEd: HIPAA PRIVACy ANd SECURITy TRAINING FOR PHySICIAN AdMINISTRATION STAFF - $95

❏

20705. ROlE-BASEd: HIPAA PRIVACy ANd SECURITy TRAINING FOR THE PRIVACy OFFICIAl - PART 1 - $95

❏

20706. ROlE-BASEd: HIPAA PRIVACy ANd SECURITy TRAINING FOR THE PRIVACy OFFICIAl - PART 2 - $95

20900. PROFESSIONAL cERTIFIcATION: HIPAA AcAdEMY cURRIcULUM

❏

20901. HIPAA ACAdEMy: HIPAA INTROdUCTION - $95

❏

20902. HIPAA ACAdEMy: INTROdUCTION TO HIPAA PRIVACy - $95

❏

20903. HIPAA ACAdEMy: AdVANCEd HIPAA PRIVACy TOPICS - $95

❏

20904. HIPAA ACAdEMy: HIPAA STANdARdS FOR ElECTRONIC TRANSACTIONS - $95

❏

20905. HIPAA ACAdEMy: INTROdUCTION TO HIPAA SECURITy - $95

❏

20906. HIPAA ACAdEMy: AdVANCEd HIPAA SECURITy - $95

❏

20907. HIPAA ACAdEMy: AdMINISTRATIVE SAFEGUARdS - $95

❏

20908. HIPAA ACAdEMy: PHySICAl ANd TECHNICAl SAFEGUARdS - $95

❏

20909. HIPAA ACAdEMy: SECURITy TECHNOlOGy FUNdAMENTAlS - $95

21200. AdvANcEd HIPAA SEcURITY cOURSES

❏

21201. BASIC HEAlTH INFORMATION SECURITy TRAINING (AlSO COURSE 20004) - $95

❏

21202. AdVANCEd HIPAA POlICy ANd PROCEdURE dEVElOPMENT (AlSO COURSE 20101) - $95

❏

21203. AdVANCEd HIPAA BUSINESS ASSOCIATE RElATIONSHIPS (AlSO COURSE 20102) - $95

❏

21204. HIPAA SECURITy CONTINGENCy PlANNING - $95

❏

21205. AdVANCEd dATA AUdIT SECURITy - PART I - $95

❏

21206. AdVANCEd dATA AUdIT SECURITy - PART II - $95

$ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ TOTAL: $ _______

(5)

Train for ComplianCe

Course registration form

cOURSE REGISTRATION - TRAIN FOR EMERGENcY MANAGEMENT

30000. BASIc EMERGENcY MANAGEMENT cOURSES

❏

30001. BASIC INCIdENT COMMANd SySTEM I - $95

❏

_{30002. BASIC INCIdENT COMMANd SySTEM II - $95}

❏

30003. EMERGENCy MANAGEMENT PRINCIPlES - $95

❏

_{30004. EFFECTIVE CRISIS COMMUNICATION - $95}

❏

30005. dEVElOPING A SIMUlATION/dRIll EXERCISE PROGRAM - PART 1 - $95

❏

_{30006. dEVElOPING A SIMUlATION/dRIll EXERCISE PROGRAM - PART 2 - $95}

30100. JcAHO EMERGENcY MANAGEMENT STANdARdS

❏

30101. UNdERSTANdING JCAHO EMERGENCy MANAGEMENT STANdARdS - PART 1 - $95

❏

_{30102. UNdERSTANdING JCAHO EMERGENCy MANAGEMENT STANdARdS - PART 2 - $95}

30200. EMERGENcY MANAGEMENT cHEMIcAL/BIOLOGIcAL AGENT IdENTIFIcATION

❏

30201. BIOTERRORISM: ANTHRAX - $95

❏

_{30202. BIOTERRORISM: BOTUlINUM - $95}

❏

30203. BIOTERRORISM: PlAGUE - $95

❏

_{30204. BIOTERRORISM: HEMORRHAGIC VIRUSES - $95}

❏

30205. BIOTERRORISM: TUlAREMIA - $95

❏

_{30206. BIOTERRORISM: SMAllPOX - $95}

❏

30207. BIOTERRORISM: RAdIATION I - $95

❏

_{30208. BIOTERRORISM: RAdIATION II - $95}

❏

30209. BIOTERRORISM: RAdIATION III - $95

$ _______

TOTAL: $ _______

cOURSE REGISTRATION - TRAIN FOR PATIENT SAFETY

40000. TRAIN FOR PATIENT SAFETY BASIc cONcEPTS

❏

40001. INTROdUCTION TO BASIC CONCEPTS IN PATIENT SAFETy - PART I - $95

❏

40002. INTROdUCTION TO BASIC CONCEPTS IN PATIENT SAFETy - PART II - $95

❏

40003. INTROdUCTION TO MEdICATION SAFETy - $95

❏

40004. JOINT COMMISSION ANd MEdICARE SAFETy INITIATIVES - $95

❏

40005. PATIENT SAFETy FOR ClINICIANS - $95

❏

40006. PATIENT SAFETy FOR NON-ClINICIANS - $95

❏

40007. PATIENT SAFETy IN AMBUlATORy CARE - $95

❏

40008. THE PATIENT'S ROlE IN PATIENT SAFETy - $95

$ _______

TOTAL: $ _______

(6)

$ _______

TOTAL: $ _______

Train for ComplianCe

Course registration form

cOURSE REGISTRATION - TRAIN FOR HIT

60000. TRAIN FOR HIT - EHR/HIT cORE TRAINING - vERSION 5

❏

_{60101. CPEHR/CPHIT CORE COURSE I: HIT OVERVIEw - $145}

❏

60102. CPEHR/CPHIT CORE COURSE II: lEGAl ANd REGUlATORy ASPECTS OF HIT ANd EHR - $145

❏

_{60103. CPEHR/CPHIT CORE COURSE III: EHR ANd HIT MIGRATION PATH - $145}

❏

60104. CPEHR/CPHIT CORE COURSE IV: CHANGE MANAGEMENT FOR HIT ANd EHR - $145

60100. TRAIN FOR HIT - cPEHR TRAINING - vERSION 5

❏

_{60201. CPEHR COURSE V: dATA MANAGEMENT - $145}

❏

60202. CPEHR COURSE VI: PATIENT SAFETy: CPOE, E-RX, ANd BC-MAR - $145

❏

_{60203. CPEHR COURSE VII: PERSONAl HEAlTH RECORdS (PHRS) & CARE COORdINATION - $145}

❏

60204. CPEHR COURSE VIII: INTEROPERABIlITy - $145

❏

_{60205. CPEHR COURSE IX: kNOwlEdGE MANAGEMENT - $145}

❏

60206. CPEHR COURSE X: ElECTRONIC dOCUMENT MANAGEMENT SySTEMS - $145

60200. TRAIN FOR HIT - cPHIT TRAINING - vERSION 5

❏

_{60301. CPHIT COURSE V: HIT TECHNOlOGy, PRIVACy, ANd SECURITy - $145}

❏

60302. CPHIT COURSE VI: PRINCIPlES OF HIT PROJECT MANAGEMENT - $145

❏

_{60303. CPHIT COURSE VII: MANAGING HIT RETURN ON INVESTMENT (ROI) - $145}

❏

60304. CPHIT COURSE VIII: HIT SySTEM SElECTION - $145

❏

_{60305. CPHIT COURSE IX: HIT IMPlEMENTATION ANd SUPPORT - $145}

❏

60306. CPHIT COURSE X: HEAlTH INFORMATION EXCHANGE - $145

TRAIN FOR HIT - cPEHR/cPHIT ExAMINATIONS - vERSION 5

❏

_{CPEHR CERTIFICATION EXAM - $495}

❏

CPEHR CERTIFICATION EXAM (FOR THOSE wHO HAVE PREVIOUSly TAkEN EXAM) - $395

❏

_{CPHIT CERTIFICATION EXAM - $495}

❏

CPHIT CERTIFICATION EXAM (FOR THOSE wHO HAVE PREVIOUSly TAkEN EXAM) - $395

TRAIN FOR HIT - PAcKAGES

❏

_{COMPlETE EHR 10-COURSE CURRICUlUM - $1,295}

❏

COMPlETE EHR 10-COURSE CURRICUlUM ANd CPEHR CERTIFICATION EXAMINATION - $1,495

❏

_{COMPlETE HIT 10-COURSE CURRICUlUM - $1,295}