Conference Materials

REGISTRATION INFORMATION REGISTRATION FEES REGISTRATION FORM Photocopies are acceptable. Please print or type below. Please use a separate registration form for each attendee. CONTINUING EDUCATION CHCIO This program is approved for up to 18.0 continuing education unit (CEUs) hours for use in fulfilling the continuing education requirements of the Certified Healthcare CIO (CHCIO) program. CHIME members and Affiliates may claim their CEUs for the Becker's 4th Annual Health IT and Revenue Cycle Summit conference by entering them into the Non-CHIME Continuing Education Credits form on the CHIME website: http://chimecentral.org/. HOTEL RESERVATIONS The Hyatt Regency has set aside special group rates for conference attendees. To make a reservation, please visit: https://www.beckershospitalreview. com/health-it-revenue-cycle- conference/hotel-travel.html Hyatt Regency 151 E. Wacker Drive | Chicago, IL 60601 312 565 1234 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 800-417-2035 ADA REQUEST If you require special ADA accommodations, please contact us at 800 417 2035. ONLINE REGISTRATION https://www.regonline.com/ HITConference2018 TO REGISTER: CALL 800 417 2035 • FAX 866 678 5755 • REGISTRATION@BECKERSHEALTHCARE.COM OR VISIT www.Regonline.com/HITConference2018 COMPLETE REGISTRATION FORM AND MAIL OR FAX AS FOLLOWS: Online: www.Regonline.com/HITConference2018 Mail: Make checks payable to ASC Communications LLC and mail to: 29511 Network Place, Chicago, IL 60673-1295 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 Cancellation Policy: Written cancellation requests must be received within 120 days of trans- action or by August 1, 2018, whichever is first. 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 hospital must be regis- tered 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. Becker's 4 th Annual Health IT + Revenue Cycle 2018 SEPTEMBER 19-22, 2018 • HYATT REGENCY • CHICAGO, ILLINOIS ANNUAL CONFERENCE & EXHIBITS – One reasonable registration price - come for as much of the conference as you would like! Receive multiple registrant discounts. 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 8/1/18) (After 8/1/18) 1st Attendee $800 $ __________________ $900 $ _______________ 2nd Attendee $775 $ __________________ $875 $ _______________ 3rd Attendee $750 $ __________________ $850 $ _______________ (Ask about larger group discounts) TOTAL ENCLOSED $ _______________ c Enclosed is a check, payable to ASC Communications LLC Check #: ____________________ c I authorize to charge my: c c c Credit Card Number: __________________________________ Expiration Date: _____________________ Printed Cardholder Name: _____________________________ Zip Code: ___________________________ Cardholder Billing Address: ___________________________ City/State: ___________________________ Signature: ______________________________________________ CVV#/3-digit #:______________________ First/Last Name: ______________________________________________________________________________ Degree (As you wish it to appear on your badge): ___________________________________________ Title:__________________________________________________________________________________________ Facility/Company: ____________________________________________________________________________ Address: _____________________________________________________________________________________ City/State/Zip:________________________________________________________________________________ Phone: ______________________________ Fax:___________________________________________________ Email: ________________________________________________________________________________________ GENERAL INFORMATION TO REGISTER PAYMENT INFORMATION

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