Name:_____________________________________________
Address:___________________________________________
City:____________________________State:____Zip:______
Home Tel:_____________________________________
Work Tel:_____________________________________
Fax:__________________________________________
Email address:__________________________________
EXPERIENCE
Employer:_____________________________________
Title:_________________________________________
Areas of Concern:____________________________________________________________________________
_____________________________________________________________________________________________
Call 562-430-6847 to reserve your place in the class.
Note that the COC and Payer designations require additional hours.
Complete the registration form and mail with your check to:
Reimbursement Specialist
La Palma, CA 90623
(562) 430-6847
(562) 430-6849 FAX
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