October 2014 Conference Brochure

REGISTRATION FORM Photocopies are acceptable. Please print or type below. Please use a separate registration form for each attendee. REgISTRATIOn FEES AnnUAL COnFEREnCE And 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 FEES AmOUnT FEES AmOUnT (Before 9/1/14) (After 9/1/14) 1st Attendee $700 $ _______________ $800 $ _______________ 2nd Attendee $650 $ _______________ $750 $ _______________ 3rd Attendee $625 $ _______________ $725 $ _______________ 4th Attendee or more $600 $ _______________ $700 $ _______________ (Ask about larger group discounts) ToTal EnclosEd $ ______________ pAYmEnT InFORmATIOn q Enclosed is a check, payable to ASC Communications Check #: __________________ q I authorize ASC Communications to charge my: q q q Credit Card Number: _______________________________________ Expiration Date: _____________________ Printed Cardholder Name: _________________________________________________________________________ Billing Address:____________________________________________________________________________________ City: _______________________________________________________ State: ____________ Zip ________________ Signature: __________________________________________________________ CVV#/3-digit #: _____________ COnTInUIng EdUCATIOn ACHE 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 educa- tion 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. CME 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 Credits TM . Physicians should claim only the credit com- mensurate with the extent of their participation in the activity. Nurses may claim credit for activities approved for AMA PRA Category 1 Credits TM in most states, for up to 50% of the nursing requirement for recertification. Please check with your own state association for more information. AEU This program is approved for 9.00 hours of AEU credits by BASC Provider #3672. hOTEL RESERVATIOnS Swissôtel has set aside special group rates for conference attendees. To make a reservation, go to https://resweb.passkey.com/Resweb. do?mode=welcome_ei_new&eventID=10757363 Swissôtel 323 E. Wacker Drive, Chicago, IL 60601 Phone 1-888-737-9477 • Fax 1-312-565-0540 Group name: Annual ASC Conference Group Rate: $299 Single/Double COnFEREnCE QUESTIOnS For additional information or questions regarding the conference please contact ASC Communications phone: (800) 417-2035 Fax: (866) 678-5755 Email: registration@beckershealthcare.com phone: (800) 417-2035 For Becker's ASC Review and exhibitor/ sponsorship questions contact (800) 417-2035 ASC Communications, Inc. (800) 417-2035 AdA REQUEST If you require special ADA accommodations, please contact us at (703) 836-5904 OnLInE REgISTRATIOn https://www.regonline.com/21stAnnualASC Register before September 1, 2014, and SAVE on registration! For information on exhibiting and sponsorships, call (800) 417-2035 • 30 great Surgeons, 36 Leading Administrators and 80 Surgery Center Speakers in Total • keynote Speakers Terry Bradshaw, Lolo Jones and Bill Taylor • The Best ASC Business and Clinical Conference Ever • Register by Sept. 1st! Visit www.BeckersASC.com. gEnERAL InFORmATIOn REgISTRATIOn InFORmATIOn First/Last Name: ____________________________________________________________________ Degree (As you wish it to appear on your badge):______________________________________________________ Title: _______________________________________________________________________________________________ Facility/Company: __________________________________________________________________________________ Address:____________________________________________________________________________________________ City/State/Zip: ______________________________________________________________________________________ Phone: __________________________________ Fax:_____________________________________________________ Email: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 21st 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 A T I o n S ocTobEr 23-25, 2014 S w I S S ô T E L • C H I C A G o , I L L I n o I S to REgIStER, CAll (800) 417-2035 REgISTER OnLInE AT: https://www.regonline.com/ 21stAnnualASC 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: Fax registration form with credit card information to (866) 678-5755 Call: Call (800) 417-2035 to register by phone Email: registration@beckershealthcare.com Web site: www.BeckersASC.com Cancellation Policy: Written cancellation requests must be received by Sept. 1, 2014. 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.

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