individual registration

FORM

Go to www.ACRannualmeeting.org for quick and easy registration online.

1. PERSONAL INFORMATION (please print or type clearly)
member id :

degree ( s ):

last
name :

first
name :

middle
initial :
npi no .

birth date:(dd/mm/year)

nickname

(for

Individual registrants information is required.

badge ):

Optional

mailing address :
telephone :

mobile :

fax :

e - mail :
emergency contact:

phone :

relationship :

2. SPECIAL REQUESTS
q

q I have special dietary needs.

I require assistance to fully participate in the meeting.

(Specify below.)

(Specify below.)

3. REGISTRATION FEES PRE-MEETING COURSES FEES

EARLY BIRD
BY AUG. 29

ADVANCE
BY OCT. 31

Certified Rheumatology Coding - Course Only (Nov. 14)

(Take advantage of the Practice Managers discounted fee options. See next page.)

Member
Non-Member

q $295
q $320

ABIM Maintenance of Certification (Nov. 14)

Member
q $125
Non-Member
q $180
Member Fellow-in-Training
q $75
Non-Member Fellow-in-Training*
q $100
Master
q $75
Emeritus
q $75
Member Resident/Medical Student
q no fee
Non-Member Medical Student/Resident* q no fee

q $385
q $410

q $450
q $475

q $160
q $250
q $95
q $135
q $95
q $95
q no fee
q no fee

q $180
q $260
q $100
q $145
q $100
q $100
q no fee
q no fee

Musculoskeletal Ultrasound for Rheumatologists (Nov. 14-15)

Member
q $1,320 q $1,700 q $1,920
Non-Member
q $1,920 q $2,470 q $2,785
Clinical Research Conference (Nov. 14-15)
Member
q $205
Non-Member
q $300
Member Fellow-in-Training
q $135
Non-Member Fellow-in-Training*
q $190
Master
q $115
Emeritus
q $115
Member Resident/Medical Student
q no fee
Non-Member Medical Student/Resident* q no fee

q $280
q $430
q $160
q $235
q $150
q $150
q no fee
q no fee

EARLY BIRD
BY AUG. 29

ONSITE

q $320
q $490
q $180
q $270
q $170
q $170
q no fee
q no fee

ADVANCE
BY OCT. 31

ONSITE

Basic Research Conference (Nov. 14-15)

Member
q
Non-Member
q
Member Fellow-in-Training
q
Non-Member Fellow-in-Training*
q
Master
q
Emeritus
q
Member Resident/Medical Student
q
Non-Member Medical Student/Resident* q

$205
$300
$135
$190
$115
$115
no fee
no fee

q $280
q $430
q $160
q $235
q $150
q $150
q no fee
q no fee

q $320
q $490
q $180
q $270
q $170
q $170
q no fee
q no fee

Review Course ( Nov. 15)

Member
q
Non-Member
q
Member Fellow-in-Training
q
Non-Member Fellow-in-Training*
q
Master
q
Emeritus
q
Member Resident/Medical Student
q
Non-Member Medical Student/Resident* q

$215
$315
$155
$215
$155
$155
no fee
no fee

q $315
q $490
q $205
q $290
q $205
q $205
q no fee
q no fee

q $365
q $560
q $235
q $335
q $235
q $235
q no fee
q no fee

Practice Management: Office Efficiency (Nov. 15)

(Take advantage of the Practice Managers discounted fee options. See next page.)

Member
Non-Member

q $295
q $320

q $385
q $410

q $450
q $475

AAMC Medical Education Research Certificate (MERC) Workshop (Nov. 15)

Member
q $270 q $340 q $390
Non-Member
q $390 q $510 q $600
ARHP Clinical Focus (Nov. 15)
Member
Non-Member
Emeritus
Student Member
Student Non-Member*

q $205
q $300
q $155
q no fee
q $100

q $255
q $385
q $205
q no fee
q $105

q $290
q $455
q $235
q no fee
q $120

*Non-member fellows-in-training, residents and students must include a letter from their program director, chief of service or faculty advisor to be eligible for
reduced fees.

Registration form Page 2 of 4

Last Name____________________________________ First Name____________________________________ Middle Initial_____________

4. PRACTICE MANAGEMENT FEE OPTIONS

The practice management track provides in-depth training that focuses on practical skills needed to keep rheumatology practices current with
medical coding updates, compliance rules and Federal regulations. The program includes three full days of training with interactive classroom
discussions.
Friday, November 14, 2014: Coding Course Advance training on E/M coding and clinical documentation
Saturday, November 15, 2014: Office Efficiency Tools for your practice to improve compliance and efficiency
Sunday, November 16, 2014: Practice Regulations Overview of healthcare reform changes that impact day-to-day operations
of a medical practice
EARLY BIRD
BY AUG. 29

ADVANCE
BY OCT. 31

EARLY BIRD
BY AUG. 29

ONSITE

Option 1 Friday: Coding Course + Saturday: Office Efficiency +

Sunday: Practice Regulations
Member
Non-Member

q $735
q $875

q $880
q $1,035

ADVANCE
BY OCT. 31

ONSITE

Option 2 Saturday: Office Efficiency + Sunday: Practice Regulations

Member
Non-Member

q $985
q $1,150

q $500
q $585

q $570
q $665

q $625
q $725

Option 3 Sunday, November 16, 2014: Practice Regulations

Member & Non-member

q $315

5. REGISTRATION FEES - SCIENTIFIC SESSIONS

EARLY BIRD
BY AUG. 29

ADVANCE
BY OCT. 31

EARLY BIRD
BY AUG. 29

ONSITE

ACR Scientific Sessions: Saturday, Nov. 15 - Wednesday, Nov. 19

Member
q
Non-Member
q
Member Fellow-in-Training
q
Non-Member Fellow-in-Training*
q
Master
q
Emeritus
q
Member Resident/Medical Student
q
Non-Member Medical Student/Resident* q

$435
$635
$225
$325
no fee
$220
no fee
no fee

q
q
q
q
q
q
q
q

$550
$825
$280
$425
no fee
$275
no fee
no fee

q
q
q
q
q
q
q
q

ADVANCE
BY OCT. 31

ONSITE

ARHP Scientific Sessions: Saturday, Nov. 15 - Wednesday, Nov. 19

$630
$955
$325
$490
no fee
$320
no fee
no fee

Member
Non-Member
Emeritus
Student Member
Student Non-Member*

q
q
q
q
q

$310
$485
$220
no fee
$205

q
q
q
q
q

$445
$670
$275
no fee
$210

q
q
q
q
q

$505
$775
$320
no fee
$240

*N
 on-member fellows in training, residents and students must include a letter
from their program director, chief of service or faculty advisor to be eligible
for reduced fees.

6. MEET THE PROFESSOR AND WORKSHOP FEES

Meet the Professor

Workshops

Member - $50

Non-Member - $75

Member - $100

Non-Member - $150

Select up to three choices in each time period. (Use the 3-digit codes on pages 10-13.)

1st Choice

2nd Choice

3rd Choice

SUNDAY, NOVEMBER 16

1st Choice
2nd Choice

3rd Choice

Professors (001-010)
7:45 9:15 AM

Workshops (208-209)
1:15 3:15 PM

Workshops (201-203)
7:45 9:45 AM

Workshops (210-213)
4:00 6:00 PM

Workshops (204-207)
10:30 AM 12:30 PM

Professors (021-030)
4:30 6:00 PM

Professors (011-020)
12:45 2:15 PM

continued next page

Registration form Page 3 of 4

Last Name____________________________________ First Name____________________________________ Middle Initial_____________

6. MEET THE PROFESSOR AND WORKSHOP FEES (continued from previous page)
Select up to three choices in each time period. (Use the 3-digit codes on pages 10-13.)

1st Choice

2nd Choice

3rd Choice

MONDAY, NOVEMBER 17

1st Choice
2nd Choice

Professors (031-040)
7:45 9:15 AM

Workshops (222-224)
1:15 3:15 PM

Workshops (214-217)
7:45 9:45 AM

Workshops (225-228)
4:00 6:00 PM

Workshops (218-221)
10:30 AM 12:30 PM

Professors (051-060)
4:30 6:30 PM

3rd Choice

Professors (041-050)
12:45 2:15 PM
TUESDAY, NOVEMBER 18
Professors (061-070)
7:45 9:15 AM

Workshops (236-239)
1:15 3:15 PM

Workshops (229-232)
7:45 9:45 AM

Workshops (240-242)
4:00 6:00 PM

Workshops (233-235)
10:30 AM 12:30 PM

Professors (081-090)
4:30 6:30 PM

Professors (071-080)
12:45 2:15 PM

7. ADDITIONAL ITEMS
Shuttle Bus Pass: Attendees and registered guests who have made their hotel reservation with ACR Housing will receive a complimentary busing
pass. All others (excluding metropolitan Boston, MA residents) must purchase a $50 bus pass to ride the ACR shuttle bus.

I wish to purchase _____ (quantity) bus passes at $50 each = $_____

8. GUEST REGISTRATION (18 years of age and older)

I wish to purchase _____ (quantity) at $90 each = $________

last
name :

first
name :

middle
initial :

last
name :

first
name :

middle
initial :

9. QUICK QUESTIONS
1. Is this your first annual meeting?
q Yes
q No

4. To connect at the meeting, will you:

q use the ACRs complimentary wireless

connection
q use your own data plan from your own
2. How many mobile devices including tablets
provider
do you plan to use at the meeting?
q none
5. What is your specialty? (Choose one)
q 1
q Rheumatology-Adult
q 2
q Rheumatology-Pediatric
q 3
q General practice
q 4 or more
q Orthopedics
3. What kind of devices will you use
q Pediatrics
at the meeting?
q General Practice
q iPhone
q Research
q android phone
q Other Physician (specify)
q iPad

q other tablet
q Blackberry
q Laptop

6.Which work setting best describes where you

spend the majority of your time (Choose one):

q Solo Practice
q Group Practice
q Medical School/University/
q
q
q
q

Academic Medical Center

Government
Hospital
Pharmaceutical/Biotech Industry
Other (specify)

7. What is your age range?

q 30 years or under
q 31 40
q 41 50
q 51 60
q 61 70
q 71 or over

Registration form Page 4 of 4

Last Name____________________________________ First Name____________________________________ Middle Initial_____________

10. PAYMENT INFORMATION

Full payment is due at time of registration.
Registrations received after the Early Bird or Advance deadlines will be charged at the next higher rate.
Pre-Meeting Course Fees: $_____________________________

Shuttle Bus Pass*: $_____________________________

Scientific Sessions: $_____________________________

total registration fees $______________________________

Guest(s) Fees: $_____________________________

*Attendees (including registered guests) who have made their hotel reservation with ACR Housing and residents of metropolitan Boston will receive a complimentary
busing pass. All others must purchase a $50 bus pass to ride the ACR shuttle buses.

enclosed is check

(in u.s.

#___________

in the amount of

funds only and drawn on a u.s. bank)

charge

$ ____________________

$ ___________________

to the following credit card:

Visa

made payable to the american college of rheumatology

MasterCard

credit card number

name as it appears on card

American Express

Diners Club

expiration date

cardholder signature

11. M EET THE PROFESSOR and WORKSHOP PAYMENT

Fees for Meet the Professor sessions and Workshops can be paid by credit card only.
TOTAL MEET THE PROFESSOR/WORKSHOP FEES $____________
______ Maximum number of sessions you wish to attend and for which you wish to be charged.

use same credit card as listed above

charge

$ ____________________

to the following credit card:

Visa

MasterCard

credit card number

name as it appears on card

American Express

expiration date

cardholder signature

If mailing or faxing registration forms, be sure to include all four pages.

This form is for individual registration only. For groups of 10 or more, contact ACR at acrgroups@cmrus.com.
MAIL:  ACR Registration and Housing
33 New Montgomery Street, Suite 1100
San Francisco, CA 94105

FAX:  (415) 293-5231

QUESTIONS:  Phone (Mon-Fri, 9:00 am - 9:00 pm ET)

(800) 990-2446 (US & Canada)
(415) 979-2286 (International)
E-mail: acrreg@cmrus.com

Diners Club