Becker's Spine Review

To regisTer, call (800) 417-2035 RegistRation foRm Photocopies are acceptable. Please print or type below. Please use a separate registration form for each attendee. 20th Annual Ambulatory Surgery Centers Conference Improving Profitability and Business and legal Issues f R o m B E C k E R ' S A S C R E V I E w , A S C C o m m u N I C AT I o N S ocTobEr 24-26, 2013 SwiSSotel • ChiCago, illinoiS RegISTRATION INFORmATION First/Last Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Degree (As you wish it to appear on your badge): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ geNeRAl INFORmATION CONTINuINg eduCATION ACHE Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ASC Communications is authorized to award 14.5 hours of pre-approved ACHE Qualified Education credits (non-ACHE) for this program toward advancement, or recertification in the American College of Healthcare Executives. Participants in this program wishing to have the continuing education hours applied toward ACHE Qualified Education credits should indicate their attendance when submitting application to the American College of Healthcare Executives for advancement or recertification. City/State/Zip: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ CME Title: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Facility/Company: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Phone: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Fax: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Email: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ RegISTRATION FeeS ANNuAl CONFeReNCe & exhIBITS Receive multiple registrant discount(s). The more people you send, the greater discount you receive. The prices listed below are per person. Your registration includes all conference sessions, materials and the meal functions. RegISTRATION FeeS 1st Attendee 2nd Attendee 3rd Attendee FeeS (Before 9/1/13) $725 $675 $650 4th Attendee or more $625 (Ask about larger group discounts) AmOuNT $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ FeeS (After 9/1/13) $825 $775 $750 AmOuNT $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $725 $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ToTal EnclosEd $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ PAYmeNT INFORmATION q Enclosed is a check, payable to ASC Communications Check #: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ This CME activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the Joint Sponsorship of the Institute for Medical Studies (IMS) and ASC Communications. The Institute for Medical Studies designates this live activity for a maximum of 14.5 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Nurses may claim credit for activities approved for AMA PRA Category 1 CreditsTM in most states, for up to 50% of the nursing requirement for recertification. Please check with your own state association for more information. hOTel ReSeRVATIONS Swissotel has set aside special group rates for conference attendees. To make a reservation, go to https://resweb.passkey.com/go/aschospitals Swissotel 323 E. Wacker Drive, Chicago, IL 60601 Phone 1-888-737-9477 Fax 1-312-565-0540 Group name: ASC Communications Inc Conference Group Rate: $299 Single/Double CONFeReNCe QueSTIONS Billing Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ State: _ _ _ _ _ _ _ _ _ _ _ _ Zip _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ For Becker's ASC Review and exhibitor/ sponsorship questions contact (800) 417-2035 Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ CVV#/3-digit #: _ _ _ _ _ _ _ _ _ _ _ _ _ q For additional information or questions regarding the conference please contact ASC Communications Phone: (800) 417-2035 Fax: (866) 678-5755 email: registration@beckershealthcare.com or, Cathy Brett Phone: 312-929-3691 email: cbrett@beckershealthcare.com ASC Communications, Inc. (800) 417-2035 I authorize ASC Communications to charge my: q q q Credit Card Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Expiration Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Printed Cardholder Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ TO RegISTeR COmPleTe RegISTRATION FORm ANd mAIl OR FAx AS FOllOWS: Mail: Make checks payable to ASC Communications, Inc. and mail to: ASC Communications, Inc., 315 Vernon Avenue, Glencoe, IL 60022 Fax registration form with credit card information to (866) 678-5755 RegISTeR ONlINe AT: https://www.regonline.com/ Call (800) 417-2035 to register by phone 20thAnnualASC registration@beckershealthcare.com Fax: Call: Email: Web site: www.BeckersASC.com Cancellation Policy: Written cancellation requests must be received by Sept. 1, 2013. Refunds are subject to a $100 processing fee. Refunds will not be made after this date. Multi-Attendee Discount Policy: To be eligible for the discount, your ASC must be registered at one time and work at the same address. Just copy the registration form for each attendee. Employees from a 2nd location are not eligible for the discount. AdA ReQueST If you require special ADA accommodations, please contact us at (703) 836-5904 ONlINe RegISTRATION https://www.regonline.com/20thAnnualASC Register before September 1, 2013, and SAVe on registration! For information on exhibiting and sponsorships, call (800) 417-2035 Visit www.BeckersASC.com.

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