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Name of Organization
Brief Description of Organization/Audience
Contact Name
Contact Phone Number
Contact Email
Date of Event
Type of Event
Type of Presentation Requested High Level (CEO, CFO)
Medium Level (Managers)
Front Desk Staff
Educators
Coders
Billing Staff
Other Please enter an 'other' value for this selection.

Project Attendance
Work Setting Health Care Payor
Health System
Medical Group
Hospital
College/University
Other Please enter an 'other' value for this selection.

Venue for Presentation
(include location and address)
Length of Presentation(hours/minute)
Frequency of Presentation Once   Multiple
Additional Comments
 

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