Continuing Education Invitation Instructions and Statements

							                     Driving Toward Strategic Integration:
                  Transition and Transparency in Health Care
                               Registration Form                                                                                   FREE
                                               November 8, 2007                                                                  EDUCATION

                                          PRIMO West Conference Center
                                                       2353 Hadley Road, Plainfield, IN 46168

Please complete a separate registration form for each individual planning to attend. This form may be photocopied.
This form may be completed electronically and forwarded by e-mail or you may print and fax. If printing, please print clearly.

Name

Credentials                                           Title

Hospital

Business Address

City

State                          Zip Code

Telephone                                                                           Fax
Medicare Provider Number                 1       5

E-mail Address



Please mark if you are an (mark all that apply):
        Administrator                      LPN                   RN                 Physician                    Social Worker
        Other, please list
Please mark the break out sessions you plan to attend:
        Hospital Quality                                    Hospital Compliance
Please list any special accommodations that you require.


Individuals interested in registering for the meetings should return a completed registration form to Health Care
Excel, Attn: Hospital Quality Initiative, PO Box 3713, Terre Haute, IN 47803-0713, or fax to 812-232-6167 no later
than one week prior to the meeting. Registration forms may also be e-mailed to inhospital@hce.org.

E-mail confirmations will be sent to registered individuals approximately one week prior to the meeting to only those
individuals providing a correct e-mail address no later than the requested registration deadline. Individuals registering after
the registration deadline will not receive an e-mail confirmation.

Presentation handouts will be posted on the Internet at http://www.hce.org/Events/index.html#HQI by November 7,
2007. Casual attire is recommended. We suggest layered clothing due to temperature fluctuations in the meeting rooms.

For additional information, contact the Medicare QIO Provider Help Desk at 1-800-300-8190, or e-mail the Indiana Medicare
QIO at inhospital@hce.org.




This material was prepared by Health Care Excel, the Medicare Quality Improvement Organization (QIO) for Indiana, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily
reflect CMS policy. 8SOW-IN-HOS-07-50 09/27/2007