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Patient Friendly Billing Newsletter Order Form

Please complete noting that required fields are preceded by an asterisk (*). When finished, please click on the "submit" button located at the bottom of the form.

1. Contact Information:

*First name
Middle Initial
*Last name
Title
Employer
   
   

2. Mailing Information

Send mail to: Business Home  

*E-mail
Business address (No P.O. Boxes, please)
Address (cont.)
City
State/Province
Zip/Postal code
Work Phone
FAX
   
Home address (No P.O. Boxes, please)
Address (cont.)
City
State/Province
Zip/Postal code
Home Phone

3. Product Selection
PFB Newsletter - Nov 2007
 PFB Newsletter - Jan 2008
 PFB Newsletter - Mar 2008

PDF file download ($15.00)

Total Price $
 
 

PAYMENT INFORMATION
Charge my: Visa Mastercard
American Express Discover
*Card Number:    
*Expiration Date:    
*Cardholder's Name:    
*Cardholder's Signature:    
(Type in your name, which will be taken as your signature.)


 

 

If you are paying by check please print out this page and send it with your payments to HFMA, Dept. 77-5195, Chicago, IL 60678-5195. Make your checks payable to HFMA.