| EMTALA Issues 2006 | ORDER BY
MAIL Print and Complete This Form |
| SUBMIT THIS FORM AND PAYMENT TO:
Johnson Insurance Services LLC Attention: Connie Stengel 525 Junction Road Suite 2000 Madison, WI 53717 |
Make Check Payable
To: FEIN: 56-2435265 |
| NUMBER ATTENDING | PROGRAM | PRICE EACH | TOTAL PRICE | |
| EMTALA, Diversion, and ED Through-Put -- September 19, 2006 -- Phoenix, AZ | $ 397.00 | |||
| Please provide the following information on EACH person attending: |
| NAME |
HOSPITAL OR COMPANY | |
| ADDRESS LINE
1 |
ADDRESS LINE 2 | |
| CITY |
STATE | ZIP |
| PHONE
NUMBER |
EMAIL ADDRESS | |