Conference Materials

REGISTRATION FORM Photocopies are acceptable. Please print or type below. Please use a separate registration form for each attendee. 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. MAIN CONFERENCE ONLY FEES AMOUNT FEES AMOUNT (Before 6/1/16) (After 6/1/16) 1st Attendee $700 $ _______________ $800 $ _______________ 2nd Attendee $650 $ _______________ $750 $ _______________ 3rd Attendee $600 $ _______________ $700 $ _______________ (Ask about larger group discounts) TOTAL ENCLOSED $ ______________ PAYMENT INFORMATION q Enclosed is a check, payable to ASC Communications Check #: ____________________ q I authorize to charge my: q q q Credit Card Number:_________________________________ Expiration Date:__________________ Printed Cardholder Name: ___________________________ Zip Code: ________________________ Cardholder Billing Address: _______________________________________________________________ City/State/Zip:_____________________________________________________________________________ Signature: _____________________________________________________ CVV#/3-digit #: _________ CONTINUING EDUCATION ACHE More information coming soon! HOTEL RESERVATIONS The Fairmont has set aside special group rates for conference attendees. To make a reservation, please visit: https://resweb.passkey.com/go/beckershospital Fairmont 200 N. Columbus Dr. Chicago, IL, 60601 (312) 565-8000 CONFERENCE QUESTIONS For additional information regarding the conference, exhibiting or sponsoring please contact: Becker's Healthcare Phone: (800) 417-2035 Fax: (866) 678-5755 Email: registration@beckershealthcare.com For Becker's Hospital Review and exhibit/sponsorship questions contact: ASC Communications, Inc. 800-417-2035 ADA REQUEST If you require special ADA accommodations, please contact us at 800-417-2035 ONLINE REGISTRATION www.regonline.com/cioconference2016 Register before June 1, 2016, and SAVE on registration! For information on exhibiting and sponsorships, call 800-417-2035 For more information about Becker's Hospital Review, visit www. beckershospitalreview.com or call us at (800) 417-2035 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: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Visit www.beckershospitalreview.com/cio- health-it-summit TO REGISTER, CALL 800-417-2035 • FAX 866-678-5755 OR EMAIL: registration@beckershealthcare.com https://www.regonline.com/cioconference2016 Multi-Attendee Discount Policy: To be eligible for the discount, your hospital 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. TO REGISTER COMPLETE REGISTRATION FORM AND MAIL OR FAX AS FOLLOWS: Mail: Make checks payable to ASC Communications 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 Website: https://www.regonline.com/cioconference2016 Cancellation Policy: Written cancellation requests must be received within 120 days of transaction or by June 1, 2016, whichever is first. Refunds are subject to a $100 processing fee. Refunds will not be made after this date. Becker's Hospital Review 2nd Annual CIO/HIT + Revenue Cycle Conference July 27-28, 2015 • Chicago REGISTER ONLINE AT: https://www.regonline.com/ cioconference2016

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