HIPAA SEMINAR REGISTRATION FORM

 

Please print this form, complete and fax to the appropriate fax number below:

 
   
Practice Name:

 
   
Name:

 
       
Phone:

 

 Fax: 

 
 

I wish to attend the following seminar:

 

Location: ________________________________  Date:  _____________  Time:  _______

 

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SEMINARS
 

Location

 Time Fax
     
Tuesday, January 28th    
MidState Hospital – Main Campus – Conference Rms. 1 & 2 6:00-8:00 p.m.  (203) 699-2412
     
Wednesday, January 29th    
Lawrence & Memorial Hospital – Baker Auditorium 9:00-11:00 a.m. (860) 286-0787
St. Francis Hospital – Chawla Auditorium 6:00-8:00 p.m.   (203) 699-2412
     
Thursday, January 30th    
Norwalk Inn & Conference Center, 99 East Avenue, Norwalk 1:30-3:30 p.m. (203) 372-5293
500 Blake Street Café, 500 Blake Street, New Haven 6:00-8:00 p.m.  (203) 699-2412
     
Friday, January 31st    
Hartford Hospital – Gilman Auditorium 9:00-11:00 a.m. (203) 699-2412

 

 

NHCMA Web Site Form - 2003