Documentation, Coding, and Billing Specialist Certification (Urology)

Registration Form
Documentation, Coding, and Billing Specialist Certification (Urology)
For Coders, Billers, and Admins
Registration/Payment Details

My Registration*

For Coders, Billers, and Admins

$1,097.00

Additional Registrants

For Coders, Billers, and Admins

$1,097.00 Quantity
Item subtotal:$0.00

Enter coupon

Total

$0.00

Email Address to Send Payment Receipt To*
Contact Information
Contact Name (if different form Registrant 1 below)
Practice Name*
Practice Address (where to ship Pocket Card & Wall Chart)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Registrant Information
Registrant 1
Registrant's Name*
Registrant's Email*
Registrant's Mailing Address (for Pocket Card & Wall Chart)*

Street Address 2
Registrant 2
Registrant's Name*
Registrant's Email*
Registrant's Mailing Address (for Pocket Card & Wall Chart) [IF DIFFERENT FROM PRACTICE ADDRESS]

Street Address 2
Registrant 3
Registrant's Name*
Registrant's Email*
Registrant's Mailing Address (for Pocket Card & Wall Chart) [IF DIFFERENT FROM PRACTICE ADDRESS]

Street Address 2
Registrant 4
Registrant's Name*
Registrant's Email*
Registrant's Mailing Address (for Pocket Card & Wall Chart) [IF DIFFERENT FROM PRACTICE ADDRESS]

Street Address 2
Registrant 5
Registrant's Name*
Registrant's Email*
Registrant's Mailing Address (for Pocket Card & Wall Chart) [IF DIFFERENT FROM PRACTICE ADDRESS]

Street Address 2
Registrant 6
Registrant's Name*
Registrant's Email*
Registrant's Mailing Address (for Pocket Card & Wall Chart) [IF DIFFERENT FROM PRACTICE ADDRESS]

Street Address 2
Registrant 7
Registrant's Name*
Registrant's Email*
Registrant's Mailing Address (for Pocket Card & Wall Chart) [IF DIFFERENT FROM PRACTICE ADDRESS]

Street Address 2
Should be Empty:

Registration Form