Pain Medicine for Non-Pain Specialists - CME

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General Information FEES • MD’s: $325 (USD) • Reduced Fee for Residents*/Fellows in Training* and Allied Health Professionals: $230 (USD) *with a letter of verification from Department Chair Register Early, Space is Limited. All foreign payments must be made by a draft on a United States bank or by Visa or Mastercard. If paying by check, make it payable to Harvard Medical School and mail with the completed registration form to: Harvard Medical School - Department of Continuing Education, P.O. Box 825, Boston, MA 02117-0825. If paying by credit card, fax the completed registration form to (617) 384-8686, mail it to the above address or register online at www.cme.hms.harvard.edu/courses/painmedicine. Telephone registrations are not accepted. Inquiries should be directed to the above address, made by phone: (617) 384-8600, Monday - Friday, 10am to 4pm (EST), or by email: hms-cme@hms.harvard.edu. Upon receipt of registration, a confirmation letter will be mailed to the address listed on the form. REFUND POLICY A handling fee of $60 is deducted for cancellation. Refund requests must be received by mail or fax one week prior to the course. No refunds will be made thereafter. ACCREDITATION Harvard Medical School is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Harvard Medical School designates this educational activity for a maximum of 8 AMA PRA Category 1 Credit(s) TM . Physicians should only claim credit commensurate with the extent of their participation in the activity. Beth Israel Deaconess Medical Center Patient Care Services is an approved provider of continuing education by the Massachusetts Association of Registered Nurses, Inc., an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Nursing continuing education contact hours have been applied for through the BIDMC Patient Care Services.
October 7, 2006 Class # 261290 ➀ COURSE REGISTRATION - Please print clearly or type. Full Name _______________________________________________________ Last First Middle Initial Degree_________________________________________________________ Mailing Address___________________________________________________ Street _______________________________________________________________ City State Zip Code Daytime Phone ( )_______________ Fax Number ( )______________ Email Address____________________________________________________ ❍ Please check if you wish to be excluded from receiving email notices of future Harvard Medical School - Department of Continuing Education programs. Professional School Attended_____________________Year of Graduation_____ Profession_______________________________________________________ Principal Specialty_________________________________________________ Board Certified? Yes ❍ No ❍ Organization Affiliation _____________________ ➁ CHOOSE YOUR FEE - Please check one: ❍ MD’s: $325 (USD) Pain Medicine for Non-Pain Specialists ❍ Residents*/Fellows in Training*/Allied Health Professionals: $230 (USD) * A letter of verification from Department Chair must accompany application for a reduced fee. ➂ FORM OF PAYMENT - Please check one: ❍ Check is Enclosed. Please make your check payable to Harvard Medical School and mail it with this registration form to: Harvard Medical School - Department of Continuing Education P.O. Box 825, Boston, MA 02117-0825 ❍ Bill My Credit Card: ❍ VISA ❍ MASTERCARD _________-_________-_________-__________ _______/________ Credit Card Number Expiration Date _______________________________________ $_______________ Signature Tuition Fee _______________________________________ Name as it Appears on Card Registrations paid by credit card may be faxed to 617-384-8686, or submitted online at www.cme.hms.harvard.edu/courses/painmedicine Online Registrants: Add the first three letters Source Code: WEB of the source code found here
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