Sixth Annual Meeting

June 25 & 26, 2013

Folsom, CA

Registration Form (One form for each person, please.)

Join us for our annual meeting, featuring guest speakers, networking opportunities, and discussions on current issues impacting our rural health clinics.

Conference Information and Pricing

Registration Deadline: June 3, 2013 Note: After June 3, late fee is applicable.

Tuesday - 8am to Noon - Session #1 - "RHC 101": $75 for CARHC members, $150 for non-members includes registration and materials. Space is limited. (Session is highly recommended for new clinic leaders and great refresher for experienced leaders.)

Tuesday - 8am to Noon - Session #2 - "Billing and Coding": $75 for CARHC members, $150 for non-members includes registration and materials. Space is limited. (Session is highly recommended for billers, coders and great refresher for experienced leaders.)

Tuesday - 8am to Noon - Session #3 - "Cost Reports": $75 for CARHC members, $150 for non-members includes registration and materials. Space is limited. (Session is highly recommended for both new and experienced clinic leaders and great refresher for leaders.)

Tuesday - Noon to 1 pm - Lunch on your own. Box lunch available for purchase at time of registration.

Tuesday - 1 pm to 5 pm and Wednesday - 8:30 am to 5:00 pm - Main Conference: $175 for CARHC members, $250 for non-members includes registration, materials and Wednesday lunch. Space is limited.

Tuesday - 5 pm to 6:30 pm - Networking Reception: Free

Hotel Accommodations: Lake Natoma Inn, 702 Gold Lake Drive, Folsom, CA 95630 has set aside a group of rooms at the rate of $95/night plus taxes. www.LakeNatomaInn.com This rate includes Continental Breakfast and complimentary guest room internet and parking. Please note that reservations must be made before Monday, June 3, 2013 to be eligible for this special rate. Call 916-351-1500 and ask for the CARHC special rate. (Group code CARHC or mention California Association of Rural Health Clinics.) You may email to . The Folsom Chamber of Commerce is providing Complimentary Shuttle Service from the Sacramento International Airport (SMF). For the complimentary Super Shuttle transportation, the attendees need to go to www.SuperShuttle.com and book their reservations on line. On the “Payment Option” screen, select direct bill account and the account number to type in is 092FOL33895

Food and Beverages: Tuesday - On your own except for the Reception in evening. Many dining options in Historic Folsom just a short walk away or order a Box Lunch (pre-order next page).

Wednesday - All Day All Inclusive (Lunch and Breaks)

Confirmation: Upon receipt of completed registration form and fees, a confirmation letter with detailed location information and directions will be emailed to each registrant.

No refunds permitted, but substitutions will be allowed.

Questions: Please contact Linda Findley at 916-865-1897 or .

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Conference Participant Information

Registration Deadline: June 3, 2013 Note: After June 3, late fee is applicable.

Please check all that apply.

c CARHC Member

c Non-Member

c State Agency Employee (No Charge)

c Speaker (No Charge)

c Exhibitor / Sponsor (No Additional Fee)

Contact Information: (Please Print) (for Participants List)

Name:
Title:
Organization:
Address:
City, State, Zip:
Daytime Phone: / Daytime Fax:
Email (Required):
Website:
Type Clinic: / c Independent c Provider-Based (If not a clinic, please choose which breakout you will attend.)
(for breakout session headcount)

þ I will attend: (for headcount) Invoice Amount)

c Tuesday AM “RHC 101” $ 75 members/$150 non-members $

c Tuesday AM “Billing and Coding” $ 75 members/$150 non-members $

c Tuesday AM “Cost Reports” $ 75 members/$150 non-members $

c Tuesday Box Lunch $ 16 $

c Tuesday Networking Reception Free $ N/A

c Conference (Tuesday & Wednesday) (Includes Wednesday lunch) $175 members/$250 non-members $

c Late Registration Charge (after June 3) $50 $

Total Due $

Special needs? Please provide a written description. c Vegetarian c Other ______

Continuing Education? License State ______Number______Type ______

Questions: Please contact Linda Findley at 916-865-1897 or .