essentials in practice management in ipm comprehensive review course

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American Society of Interventional Pain Physicians e Voice of Interventional Pain Management since 1998 ESSENTIALS IN PRACTICE MANAGEMENT IN IPM COMPREHENSIVE REVIEW COURSE AND COMPETENCY EXAMINATION UP TO 14.25 AMA PRA CATEGORY 1 CREDITS™ CONTROLLED SUBSTANCE MANAGEMENT WHAT YOU NEED TO KNOW COMPREHENSIVE REVIEW COURSE AND COMPETENCY EXAMINATION UP TO 14 AMA PRA CATEGORY 1 CREDITS™ OCTOBER 4-6, 2013 | DENVER, COLORADO HOTEL & REVIEW COURSE LOCATION: The Westin Denver Downtown, 1672 Lawrence Street, Denver, CO 80202 | 1-303-572-9100 SPECIAL DISCOUNTS: • $100 each for Interventional Techniques in Chronic Spinal Pain and Chronic Non-Spinal Pain • 10% off Foundations, Clinical Aspects, and/or Board Review Self-Assessment • 20% off Essentials of Practice Management: Billing, Coding, and Compliance in Interventional Pain Management • 50% Off Meeting Fee to Fellows & Residents • Special room rates though September 12, 2013 ASIPP® EDUCATIONAL SERVICES | EXCELLENCE IN EDUCATION OF INTERVENTIONAL PAIN PHYSICIANS

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Page 1: Essentials in Practice Management in IPM  Comprehensive Review Course

American Society of Interventional Pain PhysiciansThe Voice of Interventional Pain Management since 1998

ESSENTIALS IN PRACTICE MANAGEMENT

IN IPM COMPREHENSIVE REVIEW COURSEAND COMPETENCY EXAMINATION

UP TO 14.25 AMA PRA CATEGORY 1 CREDITS™

CONTROLLED SUBSTANCE MANAGEMENT

WHAT YOU NEED TO KNOW COMPREHENSIVE REVIEW COURSE AND COMPETENCY EXAMINATION

UP TO 14 AMA PRA CATEGORY 1 CREDITS™

OCTOBER 4-6, 2013 | DENVER, COLORADOHOTEL & REVIEW COURSE LOCATION:

The Westin Denver Downtown, 1672 Lawrence Street, Denver, CO 80202 | 1-303-572-9100

SPECIAL DISCOUNTS:• $100 each for Interventional Techniques in Chronic Spinal Pain and Chronic Non-Spinal Pain

• 10% off Foundations, Clinical Aspects, and/or Board Review Self-Assessment• 20% off Essentials of Practice Management: Billing, Coding,

and Compliance in Interventional Pain Management• 50% Off Meeting Fee to Fellows & Residents

• Special room rates though September 12, 2013

ASIPP® EDUCATIONAL SERVICES | EXCELLENCE IN EDUCATION OF INTERVENTIONAL PAIN PHYSICIANS

Page 2: Essentials in Practice Management in IPM  Comprehensive Review Course

FROM THE CHAIRMAN

On behalf of the Board of Directors of the American Society

of Interventional Pain Physicians (ASIPP), I would like to

invite you to one of the most comprehensive and useful

educational conferences available anywhere. The ASIPP

Comprehensive Review Courses and Exams in Controlled

Substance Management and Practice Management will be

held in Denver, Colorado, on October 4-6, 2013.

Since we began offering the Competency Review courses in 2005, it has become

recognized as a “must attend” training event for interventional pain physicians

and physicians just entering interventional pain management or in-training and

physiciansappearing for board examinations by various boards. The Coding,

Compliance and Practice Management is so beneficial to practices, both office-based

and ASCs, that many physicians send their staff early to keep them current on the

cutting edge aspects of practice management.

These intensive review courses are designed to present interventional pain

management specialists and other health care providers an in-depth review of

multiple areas of interventional pain management—the areas we were never taught,

yet are crucial for our survival. The course features many nationally recognized

experts in pain management billing and coding and practice management as well

as controlled substance management. In today’s environment of regulations and

litigations, you can’t afford not to broaden your knowledge and refresh your skills in

these areas.

In addition to the review course, the American Board of Interventional Pain Physicians

(for physicians) and the American Association of Allied Pain Management Professionals

(for non-physicians) offers the opportunity for examination in order for physicians to

obtain competency certification to and non-physicians to obtain associate certificates

in Controlled Substance Management and Coding, Compliance, and Practice

Management.

We hope you will join us in exciting Denver, for this once-a-year educational event.

Whether you have practiced pain medicine or interventional pain management for

years, if you are new to the discipline, or if you are in training—the ever-changing

field of medicine, practice management, and rules and regulations associated with

these specialties makes this an essential course for you.

Sincerely,

Laxmaiah Manchikanti, MD

Chairman of the Board and Chief Executive Officer, ASIPP

AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS2

ESSENTIALS IN PRACTICE MANAGEMENT IN IPM COMPREHENSIVE REVIEW COURSE AND COMPETENCY EXAMINATIONCONTROLLED SUBSTANCE MANAGEMENT: WHAT YOU NEED TO KNOW COMPREHENSIVE REVIEW COURSE AND COMPETENCY EXAMINATIONOCTOBER 4-6, 2013 | DENVER, COLORADO

American Society of Interventional Pain PhysiciansTHE VOICE OF INTERVENTIONAL PAIN MANAGEMENT SINCE 199881 Lakeview Drive, Paducah, KY 42001Phone: 270.554.9412 | Fax: 270.554-5394E-Mail: [email protected] Site: www.asipp.orgCHAIRMAN OF THE BOARD ANDCHIEF EXECUTIVE OFFICER Laxmaiah Manchikanti, MD—Paducah, KYPRESIDENT Hans C. Hansen, MD—Conover, NCIMMEDIATE PAST PRESIDENTFrank J.E. Falco, MD—Newark, DE PRESIDENT-ELECTRamsin M. Benyamin, MD—Bloomington, ILFIRST EXECUTIVE VICE PRESIDENTDavid L. Caraway, MD, PhD—Huntington, WVSECOND EXECUTIVE VICE PRESIDENTAaron K. Calodney, MD— Tyler, TXVICE PRESIDENT STRATEGIC PLANNINGFrancis Riegler, MD—Malibu, CASECRETARYPeter S. Staats, MD—Shrewsbury, NJTREASURERDavid Bryce, MD—Middleton, WILIFETIME DIRECTORSCyrus E. Bakhit, MD—Roanoke, VALaxmaiah Manchikanti, MD—Paducah, KYVijay Singh, MD—Niagara, WIDIRECTORS AT LARGESalahadin Abdi, MD—Houston, TXMark V. Boswell, MD, PhD—Louisville, KY Harold Cordner, MD—Sebastian, FLTim Deer, MD—Charleston, WVSudhir Diwan, MD—New York, NYHaroon Hameed, MD—Blatimore, MDMariam Hameed, MD—Boston, MAJoshua A Hirsch, MD—Boston, MAAlan Kaye, MD, PhD—River Ridge, LAAllan T. Parr, MD—Covington, LA Gabor B. Racz, MD—Lubbock, TXDavid M. Schultz, MD—Minneapolis, MN John R. Swicegood, MD—Fort Smith, ARAndrea M. Trescot, MD—Eagle River, AKDIRECTORS EMERITUSStandiford Helm II, MD—Laguna Hills, CA David S. Kloth, MD—Danbury, CTPAIN PHYSICIAN EDITOR-IN-CHIEFAlan David Kaye, MD, PhD—New Orleans, LAAMA DELEGATESLee T. Snook, MD—Sacramento, CAHaroon Hameed, MD—Baltimore, MDSTAFFMelinda Martin, Director of OperationsRay Lane, Director of Public RelationsHolly Long, Coordinator of Editorial ServicesVidyasagar Pampati, Statistician and ProgrammerPaula Reynolds Spear, Meeting CoordinatorTom Prigge, Multimedia SpecialistCindy Rogers, Administrative AssistantSummer Moffitt, Administrative AssistantGOVERNMENT AFFAIRS COUNSELSenator Tim Hutchinson & Randi Hutchinson, Esq., Dickstein Shapiro, LLP, 1825 Eye Street NWWashington, DC 20006 [email protected] Mortier, Legislative PartnerRyan, Mackinnon, Vasapoli and Berzok, LLP1634 Eye Street NW, Suite 1200Washington, DC 20006GENERAL COUNSELErin Brisbay McMahonJD, Wyatt, Tarrant & Combs, LLP, 250 West Main Street, Suite 1600Lexington, KY 40507859.288.7452 | [email protected]

Page 3: Essentials in Practice Management in IPM  Comprehensive Review Course

STATEMENT OF NEED

These two-day comprehensive review courses are planned as a CME activity to prepare for competency certification or an in-depth review in areas of What You Need to Know in Controlled Substance Management and Essentials in Practice Management in IPM. This review course is based on the American Board of Interventional Pain Physicians’ specifications for competency certification examinations.

This course will provide in-depth evaluation of the knowledge of the participants with extensive review of subject(s).

As part of this comprehensive, in-depth, intense two-day review course, ASIPP will provide participants with online mateiral of the lectures.EDUCATIONAL OBJECTIVES/TARGET AUDIENCE

The courses are intended to present interventional pain management specialists, nurses, and other healthcare providers an in-depth review of multiple areas of interventional pain management including What You Need to Know in Controlled Substance Management.

Educational Objectives for What You Need to Know in Controlled Substance Management:

• Review basic science and core concepts• Discuss pharmacology• Identify clinical use and effectiveness• Identify substance abuse• Discuss topics with documentation, regulatory issues, legal issues, and ethical issues

Educational Objectives for Essentials in Practice Management in IPM:

• Discuss documentation• Review practice management topics• Discuss coding and billing• Examine compliance issues

OUTCOME

Participants in the What You Need to Know in Controlled Substance Management Course should be able to apply the fundamental concepts of managing controlled substances in your practice, from pharmacology and the clinical uses to identifying abuse and the legal aspects of prescribing, for better outcomes and reduced side effects. Participants in the Essentials in Practice Management in IPM Course will learn to operate comprehensive interventional pain care centers more efficiently, so that patients will receive the best care available.

AMERICANS WITH DISABILITIES ACT AND SPECIAL SERVICES

Organizers fully comply with the legal requirements of the Americans with Disabilities Act and the rules and regulations thereof. If any participant in this educational activity is in need of accommodations, please contact the organizers at (270) 554-9412 at least 10 days prior to the conference.

ACCREDITATION STATEMENT

This CME activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education thru the Joint Sponsorship of the Institute for Medical Studies (IMS) and the American Society of Interventional Pain Physicians. The Institute for Medical Studies is accredited by the ACCME to provide continuing medical education for physicians.

CATEGORY I CREDIT

The Institute for Medical Studies designates this educational activity

for a maximum of 14 AMA PRA Category 1 Credits ™ for Controlled Substance Management and 14.25 AMA PRA Category 1 Credits™ for the Essentials in Practice Management. Physicians should only claim credit commensurate with the extent of their participation in the activity.

RN, NP AND PA CREDIT

Nurses may claim credit for activities approved for AMA PRA Category 1 Credits™ in most states, for up to 14 AMA PRA Category 1 Credits™ for Controlled Substance Management and 14.25 AMA PRA Category 1 Credits™ for the Essentials in Practice Management.

Nurse Practitioners: The American Academy of Nurse Practitioners (AANP) accepts 14 AMA PRA Category 1 Credits™ for Controlled Substance Management and 14.25 AMA PRA Category 1 Credits™ for the Essentials in Practice Management from organizations accredited by the ACCME. IMS is accredited to provide continuing medical education for physicians and will provide nurse practitioners who successfully complete each activity with a certificate of participation indicating that the activity was designated for the catagory credits listed above. The American Academy of Physician Assistants (AAPA) accepts AMA PRA Category 1 Credits™ from organizations accredited by the ACCME. The provider of this program, the Institute for Medical Studies, is accredited by the ACCME and designates this educational activity for a maximum of 14 AMA PRA Category 1 Credits™ for Controlled Substance Management and 14.25 AMA PRA Category 1 Credits™ for the Essentials in Practice Management. Physician assistants should only claim credit commensurate with the extent of their participation in the activity.

CODING CREDIT

ASIPP has applied for approval of the American Academy of Professional Coders for the appropriate Continuing Education Units. Granting of this approval in no way constitutes endorsement by the Academy of the program, content or any sponsors.

There is no commercial support for this course. No duplication or distribution of materials, or recording of lectures associated. There is NO commercial support for this course.

ACCOMMODATIONSTHE WESTIN DENVER DOWNTOWN1672 LAWRENCE STREETDENVER, CO 80202(303) 572-9100 Located in renowned Lower Downtown Denver, we’re a stroll away from the 16th Street pedestrian mall, Denver Center for Performing Arts, Convention Center, museums, and entertainment. We’re also within walking distance of professional sports venues. Inform the hotel that you are booking for ASIPP. We have secured a group room rate of $169. Reserve rooms early—all unbooked rooms will be released on September 12, 2013.

AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS 3

ESSENTIALS IN PRACTICE MANAGEMENT IN IPM COMPREHENSIVE REVIEW COURSE AND COMPETENCY EXAMINATIONCONTROLLED SUBSTANCE MANAGEMENT: WHAT YOU NEED TO KNOW COMPREHENSIVE REVIEW COURSE AND COMPETENCY EXAMINATION

OCTOBER 4-6, 2013 | DENVER, COLORADO

Page 4: Essentials in Practice Management in IPM  Comprehensive Review Course

AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS4

CONTROLLED SUBSTANCE MANAGEMENT: WHAT YOU NEED TO KNOW COMPREHENSIVE REVIEW COURSE AND COMPETENCY EXAMINATIONOCTOBER 4-6, 2013 | DENVER, COLORADO

No duplication or distribution of materials, or recording of lectures associated with this conference is permitted without express written consent of the American Society of Interventional Pain Physicians. All rights reserved.

7:00am–8:00am REGISTRATION AND BREAKFAST

8:00am–8:30am Introduction and Status of Drug Abuse Alan Kaye, MD, PhD

8:30am–9:30am A DEA Perspective of the Drug Abuse Epidemic Shane Pitts

9:30am–10:15am Comprehensive Assessment and Documentation of a Chronic Pain Patient Susan Blank, MD

10:15am–10:45am BREAK

10:45am–11:30am Application of Opioid Guidelines and Documentation Laxmaiah Manchikanti, MD

11:30am – 12:15pm Terminology, Mechanisms and Management of Abuse and Addictive Disorders Sanford Silverman, MD

12:15pm 1:15pm LUNCH (provided)

1:15pm–2:00pm Anatomy, Physiology, and Psychology of Chronic Pain Alan Kaye, MD, PhD

2:00pm–2:45pm Current Drug Therapy, Non-Opioid Drug Therapy, and Other Interventions Susan Blank, MD

2:45pm–3:30pm Controlled Substance Pharmacology: Non-Opioids, Benzodizepines, Sedatives, and Hypnotics Sanford Silverman, MD

3:30pm–4:00pm BREAK

4:00pm–4:45pm Opioid Pharmacology, Interactions, and Side Effects Alan Kaye, MD, PhD

4:45pm–5:30pm Adherence Monitoring and Drug Testing Laxmaiah Manchikanti, MD

7:30am–8:30am REGISTRATION & CONTINENTAL BREAKFAST

8:30am–9:30am Critical Review of Effectiveness of Opioids in Chronic Pain Susan Blank, MD

9:30am–10:30am Dealing with a Difficult Patient: Demanding, Manipulative, and Seductive Sanford Silverman, MD

10:30am–11:00am BREAK

11:00am–12:00am Preventing and Responding to Drug Investigations of Your Practice Jean Veilleux, JD

12:00 am–1:00pm Assessment and Management of Drug Dependency and Withdrawal in Patients and Health Care Team Sanford Silverman, MD

1:00pm–2:00pm LUNCH (provided)

2:00pm–3:00pm Office Detoxification Sanford Silverman, MD

3:00pm–3:30pm BREAK

3:30pm–5:00pm Ethics in Interventional Pain Management Gail Van Norman, MD

EXAMINATION - WHAT YOU NEED TO KNOW IN CONTROLLED SUBSTANCE MANAGEMENT

7:00am BREAKFAST AND REGISTRATION

7:45am Test Instruction and Examination (You will have 2 hours to complete the 100 question examination)

WHAT YOU NEED TO KNOW IN CONTROLLED SUBSTANCE MANAGEMENT

FRIDAY OCTOBER 4, 2013

WHAT YOU NEED TO KNOW IN CONTROLLED SUBSTANCE MANAGEMENT

SATURDAY OCTOBER 5, 2013

WHAT YOU NEED TO KNOW IN CONTROLLED SUBSTANCE MANAGEMENT

SUNDAY OCTOBER 6, 2013

Page 5: Essentials in Practice Management in IPM  Comprehensive Review Course

AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS 5

ESSENTIALS IN PRACTICE MANAGEMENT IN IPM COMPREHENSIVE REVIEW COURSE AND COMPETENCY EXAMINATIONOCTOBER 4-6, 2013 | DENVER, COLORADO

7:00am–8:00am REGISTRATION & CONTINENTAL BREAKFAST

8:00am–8:30am Introduction Laxmaiah Manchikanti, MD

8:30am–9:30am An Introduction to Fraud, Abuse, Compliance, and Defense Vicki Myckowiak, JD

9:30am–10:30am Documentation for Evaluation and Management Services Marvel Hammer, RN, CPC

10:30am–10:45am BREAK

10:45am–11:45am Coding for Evaluation and Management Services Marvel Hammer, RN, CPC

11:45am 12:45pm LUNCH (provided)

12:45pm–1:45pm Anatomical Correlation of CPT Coding for IPM Procedures Marvel Hammer, RN, CPC

1:45pm–2:45pm Documentation, Coding and Billing for IPM Procedures Marvel Hammer, RN, CPC

2:45pm–3:45pm ASC Versus In-Office Coding and Billing Judith Blaszczyk, RN, CPC

3:45pm–4:00pm BREAK

4:00pm–5:00pm Documentation and Coding: Physical Therapy and Behavioral and Other Sciences Marvel Hammer, RN, CPC

7:00am–8:00am REGISTRATION & BREAKFAST

8:00am–8:45am Coverage Policies, Reviews, and Appeals Judith Blaszczyk, RN, CPC

8:45am – 9:30am OIG Compliance; Good, Bad and Ugly Vicki Myckowiak, JD

9:30am– 10:15am STARK Jean Veilleux, JD

10:15am-10:45am BREAK

10:45am–11:30am HIPAA; Good, Bad and Ugly Vicki Myckowiak, JD

11:30 am–12:15pm Developing an Interventional Pain Practice: Setting it up for Success Michael Brown

12:15pm–1:15pm LUNCH (provided)

1:15pm–2:00pm Employment Law Basics Every Practitioner Needs to Know Judith Holmes, JD

2:00pm–2:45pm Financial Management: Best Practices in Revenue Cycle Management, Maximiz-ing Patient Collections, Surviving in Turbulent Times Michael Brown

2:45pm–3:30pm Risk Management: Employment Law Compliance Issues Judith Holmes, JD

3:30pm-4:00pm BREAK

4:00pm–4:45pm Handling Difficult Employees Judith Holmes, JD

EXAMINATION - ESSENTIALS IN PRACTICE MANAGEMENT IN IPM

7:00am BREAKFAST AND REGISTRATION

7:45am Test Instruction and Examination (You will have 2 hours to complete the 100 question examination)

ESSENTIALS IN PRACTICE MANAGEMENT IN IPM

FRIDAY OCTOBER 4, 2013

ESSENTIALS IN PRACTICE MANAGEMENT IN IPM

SUNDAY OCTOBER 6, 2013

ESSENTIALS IN PRACTICE MANAGEMENT IN IPM

SATURDAY OCTOBER 5, 2013

Page 6: Essentials in Practice Management in IPM  Comprehensive Review Course

PAYMENT METHOD (Please check one):

m MASTERCARD m VISA m AMERICAN EXPRESS m DISCOVER

______________________________________________________________________________________ CREDIT CARD NUMBER EXPIRATION DATE SECURITY CODE

______________________________________________________________________________________ NAME ON CARD

m CHECK CHECK NUMBER _____________________________ m ENCLOSED (Payable to ABIPP) (Your application will not be processed if payment does not accompany registration form)

_________________________________________________________________________________________SIGNATURE OF APPLICANT

Please type or print your information clearly

________________________________________________________________________________________________________________________________________________NAME (First) (Middle Initial) (Last)

______________________________________________________________________ORGANIZATION

______________________________________________________________________ORGANIZATION ADDRESS

______________________________________________________________________CITY STATE ZIP

______________________________________________________________________PHONE FAX

______________________________________________________________________E-MAIL PERSONAL DATA: (for statistical purposes only) DATE OF BIRTH ______/______/______ m MALE m FEMALE

MEDICAL DEGREE: m MD m DO m PhD m Other (specify) _______________________

I AM CURRENTLY CERTIFIED BY THE FOLLOWING BOARD(S): mm American Board of Anesthesiology m American Board of Psychiatry and Neurology m American Board of Physical Medicine & Rehabilitationm ABA Subspecialty in Pain Medicine m Fellow of Interventional Pain Practice (FIPP) m American Board of Interventional Pain Physicians (ABIPP)m Other ABMS Primary Board(s) ________________________________________________________ m Other) _____________________________________________

SPECIALTY DESIGNATION: m 09 IPM m 72 Pain Medicine m Anesthesiology m Psychiatry m Neurology m Other ________________________

What percentage of your clinical practice is in the field of Interventional Pain Management: m 0% m 1–49% m 50–100%

PRIMARY PROFESSIONAL PRACTICE SETTING (please check all that apply):m Ambulatory surgery m Hospital m Office Practice m Academic m University m Administrative m Military m VA m Other

STATE LICENSE: State ____________________________________________ License Number _____________________________________________________________

PREFERRED MAILING ADDRESS m Organization m Home

RETURN COMPLETED FORM TO:ASIPP, 81 Lakeview Drive, Paducah, KY 42001 or Fax to (270) 554-5394

CANCELLATION POLICY:ASIPP reserves the right to cancel this course upon reasonable notice and will assume no financial obligation to registrants for cancellation for reasons beyond its control. Registration fees will be refunded however, costs incurred by the registrants, such as airline or hotel fees or penalties, are the responsibility of the registrants. ASIPP requires a 30-day notice of cancellation. Cancellations must be submitted in writing by September 4, 2013. An administrative fee of $200 will be assessed. Cancellations after September 4, 2013 but prior to September 25, 2013, will forfeit 50% of their registration fee. No cancellations accepted after September 25, 2013. Refunds will be sent after the conclusion of the meeting

For your convenience and faster registration, register online at www.asipp.org/meetings.htm

REGISTRATION FOR PHYSICIANS

AMERICA

N B

OA

RD

O

F INTERVENTIONAL PA

IN P

HY

SICIANS

ABIPP

PHYSICIAN WORKSHOP REGISTRATION INFORMATION

REGISTRATION FEES

Review Course in What You Need to Know in Controlled Substance Management m $700 (Member)m $900 (Non-Member)

Competency Exam in What You Need to Know in Controlled Substance Management m $600

Review Course in Essentials in Practice Management in IPMm $700 (Member)m $900 (Non-Member)

Competency Exam in Essentials in Practice Management in IPM m $600

Fellow Discount m 50% Discount

______________________________________________________________________HOME ADDRESS

______________________________________________________________________CITY STATE ZIP

______________________________________________________________________PHONE FAX

______________________________________________________________________E-MAIL

AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS6

ESSENTIALS IN PRACTICE MANAGEMENT IN IPM COMPREHENSIVE REVIEW COURSE AND COMPETENCY EXAMINATIONCONTROLLED SUBSTANCE MANAGEMENT: WHAT YOU NEED TO KNOW COMPREHENSIVE REVIEW COURSE AND COMPETENCY EXAMINATIONOCTOBER 4-6, 2013 | DENVER, COLORADO

Page 7: Essentials in Practice Management in IPM  Comprehensive Review Course

PAYMENT METHOD (Please check one):

m MASTERCARD m VISA m AMERICAN EXPRESS m DISCOVER

______________________________________________________________________________________ CREDIT CARD NUMBER EXPIRATION DATE SECURITY CODE

______________________________________________________________________________________ NAME ON CARD

m CHECK CHECK NUMBER _____________________________ m ENCLOSED (Payable to ABIPP) (Your application will not be processed if payment does not accompany registration form)

_________________________________________________________________________________________SIGNATURE OF APPLICANT

Please type or print your information clearly

________________________________________________________________________________________________________________________________________________NAME (First) (Middle Initial) (Last)

______________________________________________________________________ORGANIZATION

______________________________________________________________________ORGANIZATION ADDRESS

______________________________________________________________________CITY STATE ZIP

______________________________________________________________________PHONE FAX

______________________________________________________________________E-MAIL PERSONAL DATA: (for statistical purposes only) DATE OF BIRTH ______/______/______ m MALE m FEMALE

HIGHEST DEGREE EARNED: ______________________________________________________________________________

CERTIFICATIONS: m JD m MBA m MA m CPA m CPC m CPE m PA m NP m CRNA m RN m RT m ST m Other (specify) ________________

PROFESSIONAL QUALIFICATIONS/EXPERIENCE IN THE FIELD:

m Coding ___ years m Billing ___ years m Compliance ___ years m Practice Management ___ years

PREFERRED MAILING ADDRESS m Organization m Home

RETURN COMPLETED FORM TO:ASIPP, 81 Lakeview Drive, Paducah, KY 42001 or Fax to (270) 554-5394

CANCELLATION POLICY:ASIPP reserves the right to cancel this course upon reasonable notice and will assume no financial obligation to registrants for cancellation for reasons beyond its control. Registration fees will be refunded however, costs incurred by the registrants, such as airline or hotel fees or penalties, are the responsibility of the registrants. ASIPP requires a 30-day notice of cancellation. Cancellations must be submitted in writing by September 4, 2013. An administrative fee of $200 will be assessed. Cancellations after September 4, 2013 but prior to September 25, 2013, will forfeit 50% of their registration fee. No cancellations accepted after September 25, 2013. Refunds will be sent after the conclusion of the meeting

For your convenience and faster registration, register online at www.asipp.org/meetings.htm

REGISTRATION FOR NON-PHYSICIANS

NON-PHYSICIAN WORKSHOP REGISTRATION INFORMATION

REGISTRATION FEES

Review Course in What You Need to Know in Controlled Substance Management m $500 (Member)m $600 (Non-Member)

Competency Exam in What You Need to Know in Controlled Substance Management m $500

Review Course in Essentials in Practice Management in IPMm $500 (Member)m $600 (Non-Member)

Competency Exam in Essentials in Practice Management in IPM m $500

______________________________________________________________________HOME ADDRESS

______________________________________________________________________CITY STATE ZIP

______________________________________________________________________PHONE FAX

______________________________________________________________________E-MAIL

AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS 7

ESSENTIALS IN PRACTICE MANAGEMENT IN IPM COMPREHENSIVE REVIEW COURSE AND COMPETENCY EXAMINATIONCONTROLLED SUBSTANCE MANAGEMENT: WHAT YOU NEED TO KNOW COMPREHENSIVE REVIEW COURSE AND COMPETENCY EXAMINATION

OCTOBER 4-6, 2013 | DENVER, COLORADO

Page 8: Essentials in Practice Management in IPM  Comprehensive Review Course

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