Louisiana HIPAA & EHR Conference Registration Form

**please note that the form may take up to 30 seconds to process**

Conference Handout Binder Order Form

This year's Conference handout is a two-inch binder packed with handouts, background material, and much more. Each binder contains presentations from both days of the Conference.

If you missed the 2007 Louisiana HIPAA and EHR Conference, or if you'd just like another copy of the Conference Binder, use this form to order or click here for a form which you can use to fax or mail your order.


I. Complete the following information:
Name*:
Title:
Company:
Shipping address:

City:
State:
Zip code:
Telephone*:
Fax number:
Email address*:
* required fields


II. Place your order: (select only one):
	Number of handout binders from the 2007 Louisiana HIPAA and EHR Conference (includes both days)
	Cost per handout binder	$69.00
	Member of a sponsoring association or governmental employee (indicate which one)	-$10.00

	Postage and handling per binder	$9.00

III. Enter total amount due:


V. Payment Method (select only one):
	Check being mailed to HPM (9618 Jefferson Hwy., Suite D, PMB 360, Baton Rouge, LA 70809).
	Our credit card information is being faxed for security to HPM at 1-800-841-8240 (click here for fax registration form)
	Please bill me at the above address.

**please note that the form may take up to 30 seconds to process**