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HIPAA MANAGERT REGISTRATION FORM* PRACTICE NAME ________________________________________________________ ADDRESS
______________________________________________________________ PHONE
____________________________________________ FAX ________________ E-MAIL
_________________________________________________________________ CONTACT PERSON
______________________________________________________ NUMBER OF PHYSICIANS IN
YOUR PRACTICE ______________________________ NAMES OF PHYSICIANS IN YOUR PRACTICE _______________________________ _______________________________________________________________________ _______________________________________________________________________ YOU WILL RECEIVE YOUR USER
NAME AND PASSWORD UPON ENROLLMENT IN THE PROGRAM *Signing up for HIPAA ManagerT in the internet format will allow you to receive immediate updates to HIPAA news, FAQs and Best Practices. Please list who will be attending the workshops, including any additional persons who will be attending the workshops for a nominal charge. _______________________________________________________________________ MAIL REGISTRATION FORM AND
CHECK TO: Donna Kendrick Checks payable to: Morris,
Manning & Martin, LLP Total Enclosed: $ ________ If you have any questions,
please contact info@mmmlaw.com
or 404-504-5421 Return to: HIPAAT Manager |