Healthone Physician Services Group Registration/Verification Form

FACILITY REGISTRATION FOR EDCOR CLASSES

For HealthONE Physician Services - Please complete, print for signatures and fax or email to EdCor: 303-993-4378 or edcor.sherri@gmail.com

Full Name *

First Name Last Name

Phone Number *

Area Code Phone Number

Title:

(Credentials)

E-mail *

Address

Street Address

Street Address Line 2

City State

Zip Code

Facility Name *

Facility Phone Number *

Area Code Phone Number

COID# *

Manager's Name *

First Name Last Name

Manager's email *

CLASS TYPE *

OTHER CLASS:

Location:

Date of Class: *

Time: *

Do you need a book

Yes No

(FOR MANAGER TO COMPLETE AND SIGN)

I verify payment for this class for the above individual. I understand, per the Cancellation Policy, the facility will be charged if the employee does not cancel within 48 hours of the class or does not show to the class.

Will your facility pay for the book (circle one)? YES NO We have a book for the employee

Signature of Manager: _______________________________________________

Email: _________________________________________

Site: ______________________________________________COID#:____________________

I would like a copy of the ecard ID# sent to me also at the above email. YES NO