Hospital Basics

2021 Basics Class Registration

Complete the form below to register and pay online for the Credentialing School: The Basics.

If you require an invoice please contact our office via email or phone (719) 574-6016. To pay by check, please use the registration form found in the Basics class brochure here.

Registration Fee: $2,495 Two or More: $2,245 each

Please complete all fields.

You are registering for:

Nashville, TN: November 1-5, 2021

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You may use this form to register up to 5 people at one time. If you have more than 5 you may use this form again or contact our office via email or phone (719) 574-6016.

Quantity

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Total

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Registration Details

First Name

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Last Name

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Your Email

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Phone

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Title

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Company/Organization

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Name of Healthcare System (if applicable)

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Number of Medical Staff (Physicians)

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Months/Years of experience in credentialing

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Street Address

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City

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State

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Zip

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Please provide the requested information about the additional attendee that you are registering.

Please provide the requested information about the additional attendees that you are registering.

Attendee 2 Information:

Full Name

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Phone

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Title/Position

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Fax

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Months/Years of experience in credentialing

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Attendee 3 Information:

Full Name

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Phone

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Title/Position

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Fax

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Attendee 4 Information:

Full Name

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Phone

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Fax

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Attendee 5 Information:

Full Name

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Phone

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Title/Position

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Fax

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Months/Years of experience in credentialing

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Payment Details

Please complete payment details. Your payment will be processed through our secure online payment processor.

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Review and Submit

Review your submission above to make sure you have included as much information as possible. If all is correct, check the recaptcha and submit the form. Once you submit the form your payment will be processed by our secure payment processor.

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Cancellation/Refund Policy: All cancellations must be made in writing. Cancellations received at least 21 days prior to the course are eligible to receive a refund, less a processing fee of $250 per registrant.