Print and Fax to 202-296-2663 or Mail to HSR, Inc. Attn: Conference Registrar
 

Opportunities and Challenges Under Medicare Rx Reform

Hosted by the Public Hospital Pharmacy Coalition


Space is limited...so register now!

Registration Form

Required fields are indicated with asterisks (*). Please check to make sure that your e-mail address is entered correctly. When complete, please fax to (202) 296-2663, Attn: Conference Registrar; or call Health Systems Research at (202) 828-5100. If you are paying by check, please make the check payable to HSR, Inc. and mail to:

Health Systems Research, Inc.
Attn: Conference Registrar - PHPC Registration Form
1200 18th Street, NW
Suite 700
Washington, DC 20036

The registration deadline is Friday, February 20, 2004 at 5:00 p.m. Please note that registration may be closed early due to very high demand.

 
* Please indicate your registration status below by placing an "X" in the appropriate box:
I am a hospital member of the Public Hospital Pharmacy Coalition (if you aren't sure if you are a member, CLICK HERE to see a list of current members).  
I am with a public, non-profit or government organization not in PHPC.  
I am with a company or organization representing industry (Manufacturers, Wholesalers, GPOs, Pharmacy Service Companies, Consultants, Law Firms and Other Businesses).  
Your Contact Information:
First Name*  
Middle Initial  
Last Name*  
Academic Degrees *  
Job Title*  
Department  
Division  
Organization*  
Address*  
 
City*  
State*  
Country  
Zip Code*  
Telephone*  
Fax*  
E-Mail*  
Special Needs/Accommodations:  


BILLING INFORMATION (Please base your payment amount on your registration status)

I will be paying by: (circle one)
CHECK CREDIT CARD
Payment Amount: (circle one)
$299
(member)		 $399
(non-member)		 $599
(industry)
Name as shown on card:  
Billing Address (if different than above)  
City, State, Zip  
Credit Card Type*  
Credit Card Number*  
Credit Card Expiration (mm/yy)*  

*please make checks payable to HSR, Inc.

The registration fee is refundable up to February 13th. All requests for a refund prior to February 13th will receive a full refund. There will be no refunds on registration fees after February 13th although you can send a replacement from your organization or company.

Should you have further questions regarding your registration payment process, please contact:

Conference Registrar
Health Systems Research, Inc.
Phone: (202) 828-5100
Fax: (202) 728-9469
E-Mail: register@hsrnet.com

For any other questions, please contact:


Ellyn Seestedt
PHPC
E-Mail: ellyn.seestedt@ppsv.com
Phone: (202) 872-6774

Please Note: For your records, Health Systems Research's (HSR) Federal tax ID# is 52-1353811.