Medical Billing Course Online Registration Form

 

 

Last Name ________________________________First Name ____________________________MI __________

 

Business Name______________________________________________________________________________

 

Address ____________________________________________________________________________________

 

City _________________________________________________ST __________________Zip________________

 

Wk Phone ________________________Home Phone ______________________Fax______________________

 

Email Address_______________________________________________________________________________

 

[ ] I'm Paying with a check          [ ] I'm paying with a credit card          [ ] I'm paying with a money order

 

Name on Check____________________________________________________________Check #___________

 

Charge my   [ ] Visa   [ ] MasterCard   [ ] Discover  [ ] American Express

 

Card #_______________________________________CARD Security Code___________Exp. Date________________

 

Cardholder Name_______________________________Signature____________________________________

 

 

[ ] Doctor's Office Billing Online Course $299

 

[ ] Medical Billing Online Course $399

 

[ ] Basic Physical Therapy Billing Online Course $129

 

[ ] Business Continuity & Fisk Management Online Course $119

 

[ ] Introductory ICD-9-CM Online Coding Course $69

 

[ ] Introductory CPT Online Coding Course $69

 

[ ] Intermediate CPT Online Coding Course $69

 

[ ] Chiropractic 101 Online Billing Course $99

 

[ ] Compliance & HIPAA Online Seminar $69

 

[ ] CMS 1500 Claim Form Online Course $49

 

[ ] Introductory ICD-10-CM Part 1 $99

 

[ ] Introductory ICD-10-CM Part 2 $99

 

[ ] Understanding Modifiers $69

$_________________________Order Total

 

Make Checks Payable to AMBA

 

AMBA

2465 E. Main

Davis, OK  73030

 

Fax Credit Card Registrations to: (580) 369-2703