register.gotowebinar.com
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18.66.112.125
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Submitted URL: https://click.email.ngsmedicare.com/?qs=dba58243ffe45d2ef90758990cced033c70cdca3e95259dcf56c3ee2de4cbb781a15c39eed089872400d8cb744cc...
Effective URL: https://register.gotowebinar.com/register/7875390992742693134
Submission: On August 18 via manual from US — Scanned from DE
Effective URL: https://register.gotowebinar.com/register/7875390992742693134
Submission: On August 18 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form id="registrationForm" data-view="registration/body/body" data-active-view="true" style="">
<div data-bind="visible:!webinarTimesVM().allSessionsOver()" class="trainingTimesBox clearfix">
<!-- ko compose : { view : 'registration/body/body.webinarTimes' } -->
<div data-view="registration/body/body.webinarTimes" data-active-view="true" style="">
<!-- ko 'if' : showDates() === true -->
<hr>
<!-- ko 'if': !getWebinarInfo().description --><!-- /ko -->
<!-- ko 'if' : getWebinarInfo().type === 'series' --><!-- /ko -->
<!-- ko 'if' : getWebinarInfo().type !== 'series' -->
<div data-bind="'visible': getWebinarInfo().type === 'sequence'" class="row col-md-12" style="display: none;">
<div data-bind="'html': multipleSessionsText">This webinar meets 1 times.</div>
</div>
<div class="row col-md-12">
<div id="training-times" class="trainingTimesRegister">
<table class="webinarTimes" data-bind="'foreach': webinarTimesVM().webinarSessions()">
<tbody>
<!-- ko 'if' : $parent.webinarTimesVM().showFirstOfMonth($data) && $parent.getWebinarInfo().type === 'sequence'--><!-- /ko -->
<tr data-bind="css:{'past':past && !$data.inSession, 'next':next, 'future':future, 'far-future':farFuture}" class="next">
<!--ko 'if': $data.getDay() && $parent.getWebinarInfo().type === 'sequence' --><!--/ko-->
<td data-bind="'text':$data.getStartAndEndDate()">Wed, Aug 24, 2022 4:00 PM - 4:45 PM GMT</td>
</tr>
</tbody>
</table>
</div>
</div>
<!-- /ko -->
<div class="row col-md-12">
<a class="timeZone pointer launch-tz-modal" data-i18n="registration.webinarTimes.timeZone" data-bind="click:webinarTimesVM().showInMyTimeZoneDialog">Show in My Time Zone</a>
<!-- ko 'if' : webinarTimesVM().priceInfo --><!-- /ko -->
</div>
<!-- /ko -->
<!-- ko 'if' : showDates() === false && webinarTimesVM().priceInfo --><!-- /ko -->
</div><!-- /ko -->
</div>
<!-- ko 'if': getWebinarInfo().description -->
<!-- ko compose : {view:'registration/body/body.description'} -->
<div data-bind="visible:getWebinarInfo().description" data-view="registration/body/body.description" data-active-view="true" style="">
<hr>
<div class="description trainingDescription">
<div class="clearfix">
<img id="customThemeImage" data-bind="attr:{src:getBrandingInfo().themeImageUrl}" class="customImage" onerror="this.style.display='none'">
<span class="registration-description" data-bind="expander:{'expandText': moreButtonText(), 'userCollapseText': lessButtonText(), 'text':getWebinarInfo().description}">Register today for the next Medicare-covered preventive service in our
Wellness Wednesdays series! During this session will review the coverage, coding, and billing guidelines for this service. Attending this session will help ensure that your claims are submitted in accordance with the Medicare rules and
regulations.</span>
</div>
</div>
</div><!-- /ko -->
<!-- /ko -->
<!-- ko compose : {view:'registration/body/body.registrationQuestions'} -->
<div class="questions" data-view="registration/body/body.registrationQuestions" data-active-view="true" style="">
<hr>
<!-- General Questions -->
<p class="requiredMessage" data-i18n="registration.registrationQuestions.requiredInstructions">Required field</p>
<div id="studentInformation">
<div data-bind="'foreach':registrationQuestionsVM().groupedGeneralQuestions">
<div data-bind="'foreach':$data" class="row">
<div class="form-group col-sm-6 required" data-bind="'css':{required : required, 'has-error':verificationFailed }, visible:name != 'comments'">
<label class="control-label" data-bind="'attr':{'id':'registrant.' + name + 'Label', 'for':'registrant.' + name}, 'text':question" id="registrant.firstNameLabel" for="registrant.firstName">First Name</label>
<!-- ko 'if': type == 'shortAnswer' -->
<span data-bind="'text':maxSize - selectedAnswer().length, 'visible':isSelected, 'css':{'danger':maxSize - selectedAnswer().length === 0, 'warning':maxSize - selectedAnswer().length < 20}" class="charLimit"
style="display: none;">128</span>
<!-- TODO : IE8 Doesn't allow to change type of input field-->
<!-- ko 'if' : name === 'email' --><!-- /ko -->
<!-- ko 'if' : name !== 'email' -->
<input type="text" data-bind="'css':{'inputError': verificationFailed}, 'attr':{'id':'registrant.' + name, 'maxlength':maxSize, 'tabindex':tabIdx}, 'hasFocus':isSelected, 'value':selectedAnswer, 'valueUpdate': 'afterkeydown'"
class="form-control maxCharLimit" id="registrant.firstName" maxlength="128" tabindex="2">
<!-- /ko -->
<!-- /ko -->
<!-- ko 'if': type == 'multipleChoice' --><!-- /ko -->
<!-- ko 'if': verificationFailed --><!-- /ko -->
</div>
<div class="form-group col-sm-6 required" data-bind="'css':{required : required, 'has-error':verificationFailed }, visible:name != 'comments'">
<label class="control-label" data-bind="'attr':{'id':'registrant.' + name + 'Label', 'for':'registrant.' + name}, 'text':question" id="registrant.lastNameLabel" for="registrant.lastName">Last Name</label>
<!-- ko 'if': type == 'shortAnswer' -->
<span data-bind="'text':maxSize - selectedAnswer().length, 'visible':isSelected, 'css':{'danger':maxSize - selectedAnswer().length === 0, 'warning':maxSize - selectedAnswer().length < 20}" class="charLimit"
style="display: none;">128</span>
<!-- TODO : IE8 Doesn't allow to change type of input field-->
<!-- ko 'if' : name === 'email' --><!-- /ko -->
<!-- ko 'if' : name !== 'email' -->
<input type="text" data-bind="'css':{'inputError': verificationFailed}, 'attr':{'id':'registrant.' + name, 'maxlength':maxSize, 'tabindex':tabIdx}, 'hasFocus':isSelected, 'value':selectedAnswer, 'valueUpdate': 'afterkeydown'"
class="form-control maxCharLimit" id="registrant.lastName" maxlength="128" tabindex="3">
<!-- /ko -->
<!-- /ko -->
<!-- ko 'if': type == 'multipleChoice' --><!-- /ko -->
<!-- ko 'if': verificationFailed --><!-- /ko -->
</div>
</div>
<div data-bind="'foreach':$data" class="row">
<div class="form-group col-sm-6 required" data-bind="'css':{required : required, 'has-error':verificationFailed }, visible:name != 'comments'">
<label class="control-label" data-bind="'attr':{'id':'registrant.' + name + 'Label', 'for':'registrant.' + name}, 'text':question" id="registrant.emailLabel" for="registrant.email">Email Address</label>
<!-- ko 'if': type == 'shortAnswer' -->
<span data-bind="'text':maxSize - selectedAnswer().length, 'visible':isSelected, 'css':{'danger':maxSize - selectedAnswer().length === 0, 'warning':maxSize - selectedAnswer().length < 20}" class="charLimit"
style="display: none;">128</span>
<!-- TODO : IE8 Doesn't allow to change type of input field-->
<!-- ko 'if' : name === 'email' -->
<input type="email" data-bind="'css':{'inputError': verificationFailed}, 'attr':{'id':'registrant.' + name, 'maxlength':maxSize, 'tabindex':tabIdx}, 'hasFocus':isSelected, 'value':selectedAnswer, 'valueUpdate': 'afterkeydown'"
class="form-control maxCharLimit" id="registrant.email" maxlength="128" tabindex="4">
<!-- /ko -->
<!-- ko 'if' : name !== 'email' --><!-- /ko -->
<!-- /ko -->
<!-- ko 'if': type == 'multipleChoice' --><!-- /ko -->
<!-- ko 'if': verificationFailed --><!-- /ko -->
</div>
<div class="form-group col-sm-6" data-bind="'css':{required : required, 'has-error':verificationFailed }, visible:name != 'comments'">
<label class="control-label" data-bind="'attr':{'id':'registrant.' + name + 'Label', 'for':'registrant.' + name}, 'text':question" id="registrant.addressLabel" for="registrant.address">Street Address</label>
<!-- ko 'if': type == 'shortAnswer' -->
<span data-bind="'text':maxSize - selectedAnswer().length, 'visible':isSelected, 'css':{'danger':maxSize - selectedAnswer().length === 0, 'warning':maxSize - selectedAnswer().length < 20}" class="charLimit"
style="display: none;">128</span>
<!-- TODO : IE8 Doesn't allow to change type of input field-->
<!-- ko 'if' : name === 'email' --><!-- /ko -->
<!-- ko 'if' : name !== 'email' -->
<input type="text" data-bind="'css':{'inputError': verificationFailed}, 'attr':{'id':'registrant.' + name, 'maxlength':maxSize, 'tabindex':tabIdx}, 'hasFocus':isSelected, 'value':selectedAnswer, 'valueUpdate': 'afterkeydown'"
class="form-control maxCharLimit" id="registrant.address" maxlength="128" tabindex="5">
<!-- /ko -->
<!-- /ko -->
<!-- ko 'if': type == 'multipleChoice' --><!-- /ko -->
<!-- ko 'if': verificationFailed --><!-- /ko -->
</div>
</div>
<div data-bind="'foreach':$data" class="row">
<div class="form-group col-sm-6" data-bind="'css':{required : required, 'has-error':verificationFailed }, visible:name != 'comments'">
<label class="control-label" data-bind="'attr':{'id':'registrant.' + name + 'Label', 'for':'registrant.' + name}, 'text':question" id="registrant.cityLabel" for="registrant.city">City</label>
<!-- ko 'if': type == 'shortAnswer' -->
<span data-bind="'text':maxSize - selectedAnswer().length, 'visible':isSelected, 'css':{'danger':maxSize - selectedAnswer().length === 0, 'warning':maxSize - selectedAnswer().length < 20}" class="charLimit"
style="display: none;">128</span>
<!-- TODO : IE8 Doesn't allow to change type of input field-->
<!-- ko 'if' : name === 'email' --><!-- /ko -->
<!-- ko 'if' : name !== 'email' -->
<input type="text" data-bind="'css':{'inputError': verificationFailed}, 'attr':{'id':'registrant.' + name, 'maxlength':maxSize, 'tabindex':tabIdx}, 'hasFocus':isSelected, 'value':selectedAnswer, 'valueUpdate': 'afterkeydown'"
class="form-control maxCharLimit" id="registrant.city" maxlength="128" tabindex="6">
<!-- /ko -->
<!-- /ko -->
<!-- ko 'if': type == 'multipleChoice' --><!-- /ko -->
<!-- ko 'if': verificationFailed --><!-- /ko -->
</div>
<div class="form-group col-sm-6" data-bind="'css':{required : required, 'has-error':verificationFailed }, visible:name != 'comments'">
<label class="control-label" data-bind="'attr':{'id':'registrant.' + name + 'Label', 'for':'registrant.' + name}, 'text':question" id="registrant.stateLabel" for="registrant.state">State/Province</label>
<!-- ko 'if': type == 'shortAnswer' --><!-- /ko -->
<!-- ko 'if': type == 'multipleChoice' -->
<select class="form-control maxCharLimit"
data-bind="'css':{'inputError': verificationFailed}, 'attr':{'id':'registrant.' + name, 'tabindex':tabIdx}, 'hasFocus':isSelected, 'options':answers, 'optionsText':'answer', optionsCaption:$root.chooseOneText, value:selectedAnswer, optionsValue:'answerKey'"
id="registrant.state" tabindex="7">
<option value="">Choose One...</option>
<option value="None">None</option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Virgin Islands">Virgin Islands</option>
<option value="Guam">Guam</option>
<option value="Alberta">Alberta</option>
<option value="British Columbia">British Columbia</option>
<option value="Manitoba">Manitoba</option>
<option value="New Brunswick">New Brunswick</option>
<option value="Newfoundland">Newfoundland</option>
<option value="Northwest Territories">Northwest Territories</option>
<option value="Nova Scotia">Nova Scotia</option>
<option value="Nunavut">Nunavut</option>
<option value="Ontario">Ontario</option>
<option value="Prince Edward Island">Prince Edward Island</option>
<option value="Quebec">Quebec</option>
<option value="Saskatchewan">Saskatchewan</option>
<option value="Yukon">Yukon</option>
</select>
<!-- /ko -->
<!-- ko 'if': verificationFailed --><!-- /ko -->
</div>
</div>
<div data-bind="'foreach':$data" class="row">
<div class="form-group col-sm-6" data-bind="'css':{required : required, 'has-error':verificationFailed }, visible:name != 'comments'">
<label class="control-label" data-bind="'attr':{'id':'registrant.' + name + 'Label', 'for':'registrant.' + name}, 'text':question" id="registrant.zipCodeLabel" for="registrant.zipCode">Zip/Postal Code</label>
<!-- ko 'if': type == 'shortAnswer' -->
<span data-bind="'text':maxSize - selectedAnswer().length, 'visible':isSelected, 'css':{'danger':maxSize - selectedAnswer().length === 0, 'warning':maxSize - selectedAnswer().length < 20}" class="charLimit"
style="display: none;">128</span>
<!-- TODO : IE8 Doesn't allow to change type of input field-->
<!-- ko 'if' : name === 'email' --><!-- /ko -->
<!-- ko 'if' : name !== 'email' -->
<input type="text" data-bind="'css':{'inputError': verificationFailed}, 'attr':{'id':'registrant.' + name, 'maxlength':maxSize, 'tabindex':tabIdx}, 'hasFocus':isSelected, 'value':selectedAnswer, 'valueUpdate': 'afterkeydown'"
class="form-control maxCharLimit" id="registrant.zipCode" maxlength="128" tabindex="8">
<!-- /ko -->
<!-- /ko -->
<!-- ko 'if': type == 'multipleChoice' --><!-- /ko -->
<!-- ko 'if': verificationFailed --><!-- /ko -->
</div>
<div class="form-group col-sm-6" data-bind="'css':{required : required, 'has-error':verificationFailed }, visible:name != 'comments'">
<label class="control-label" data-bind="'attr':{'id':'registrant.' + name + 'Label', 'for':'registrant.' + name}, 'text':question" id="registrant.phoneLabel" for="registrant.phone">Phone Number</label>
<!-- ko 'if': type == 'shortAnswer' -->
<span data-bind="'text':maxSize - selectedAnswer().length, 'visible':isSelected, 'css':{'danger':maxSize - selectedAnswer().length === 0, 'warning':maxSize - selectedAnswer().length < 20}" class="charLimit"
style="display: none;">128</span>
<!-- TODO : IE8 Doesn't allow to change type of input field-->
<!-- ko 'if' : name === 'email' --><!-- /ko -->
<!-- ko 'if' : name !== 'email' -->
<input type="text" data-bind="'css':{'inputError': verificationFailed}, 'attr':{'id':'registrant.' + name, 'maxlength':maxSize, 'tabindex':tabIdx}, 'hasFocus':isSelected, 'value':selectedAnswer, 'valueUpdate': 'afterkeydown'"
class="form-control maxCharLimit" id="registrant.phone" maxlength="128" tabindex="9">
<!-- /ko -->
<!-- /ko -->
<!-- ko 'if': type == 'multipleChoice' --><!-- /ko -->
<!-- ko 'if': verificationFailed --><!-- /ko -->
</div>
</div>
<div data-bind="'foreach':$data" class="row">
<div class="form-group col-sm-6" data-bind="'css':{required : required, 'has-error':verificationFailed }, visible:name != 'comments'">
<label class="control-label" data-bind="'attr':{'id':'registrant.' + name + 'Label', 'for':'registrant.' + name}, 'text':question" id="registrant.organizationLabel" for="registrant.organization">Organization</label>
<!-- ko 'if': type == 'shortAnswer' -->
<span data-bind="'text':maxSize - selectedAnswer().length, 'visible':isSelected, 'css':{'danger':maxSize - selectedAnswer().length === 0, 'warning':maxSize - selectedAnswer().length < 20}" class="charLimit"
style="display: none;">128</span>
<!-- TODO : IE8 Doesn't allow to change type of input field-->
<!-- ko 'if' : name === 'email' --><!-- /ko -->
<!-- ko 'if' : name !== 'email' -->
<input type="text" data-bind="'css':{'inputError': verificationFailed}, 'attr':{'id':'registrant.' + name, 'maxlength':maxSize, 'tabindex':tabIdx}, 'hasFocus':isSelected, 'value':selectedAnswer, 'valueUpdate': 'afterkeydown'"
class="form-control maxCharLimit" id="registrant.organization" maxlength="128" tabindex="10">
<!-- /ko -->
<!-- /ko -->
<!-- ko 'if': type == 'multipleChoice' --><!-- /ko -->
<!-- ko 'if': verificationFailed --><!-- /ko -->
</div>
</div>
</div>
</div>
<!-- Custom Questions-->
<!-- ko 'if': registrationQuestionsVM().customQuestions().length > 0 -->
<hr class="skinny">
<div class="alert-info">
<p data-i18n=""></p>
</div>
<div class="row" data-bind="'foreach':registrationQuestionsVM().customQuestions">
<div class="form-group col-sm-12 required" data-bind="'css':{required : required, 'has-error':verificationFailed}">
<!-- ko 'if' : question -->
<label class="control-label" data-bind="'attr':{'id':'registrant.' + name + 'Label', 'for':'customQuestion' + $index()}, 'html':question" id="registrant.251764194Label" for="customQuestion0">Enter your provider number (PTAN/NPI)</label>
<!-- /ko -->
<!-- ko 'if': type == 'shortAnswer' -->
<span data-bind="'text':maxSize - selectedAnswer().length, visible:isSelected, css:{'danger':maxSize - selectedAnswer().length === 0, 'warning':maxSize - selectedAnswer().length < 20}" class="charLimit" style="display: none;">128</span>
<input data-bind="'css':{'inputError': verificationFailed}, 'attr':{'id':'customQuestion' + $index(), maxlength:maxSize, tabindex:tabIdx}, hasFocus:isSelected, value:selectedAnswer, valueUpdate: 'afterkeydown'"
class="form-control maxCharLimit" type="text" id="customQuestion0" maxlength="128" tabindex="11">
<!-- /ko -->
<!-- ko 'if': type == 'multipleChoice' --><!-- /ko -->
<span data-bind="visible:verificationFailed" class="help-block" style="display: none;"><i class="togo-icon togo-icon-error"></i><span data-bind="'text':errorMessage"></span></span>
</div>
<div class="form-group col-sm-12 required" data-bind="'css':{required : required, 'has-error':verificationFailed}">
<!-- ko 'if' : question -->
<label class="control-label" data-bind="'attr':{'id':'registrant.' + name + 'Label', 'for':'customQuestion' + $index()}, 'html':question" id="registrant.251764195Label" for="customQuestion1">Enter the compliance officer’s name and
email</label>
<!-- /ko -->
<!-- ko 'if': type == 'shortAnswer' -->
<span data-bind="'text':maxSize - selectedAnswer().length, visible:isSelected, css:{'danger':maxSize - selectedAnswer().length === 0, 'warning':maxSize - selectedAnswer().length < 20}" class="charLimit" style="display: none;">128</span>
<input data-bind="'css':{'inputError': verificationFailed}, 'attr':{'id':'customQuestion' + $index(), maxlength:maxSize, tabindex:tabIdx}, hasFocus:isSelected, value:selectedAnswer, valueUpdate: 'afterkeydown'"
class="form-control maxCharLimit" type="text" id="customQuestion1" maxlength="128" tabindex="12">
<!-- /ko -->
<!-- ko 'if': type == 'multipleChoice' --><!-- /ko -->
<span data-bind="visible:verificationFailed" class="help-block" style="display: none;"><i class="togo-icon togo-icon-error"></i><span data-bind="'text':errorMessage"></span></span>
</div>
<div class="form-group col-sm-12 required" data-bind="'css':{required : required, 'has-error':verificationFailed}">
<!-- ko 'if' : question -->
<label class="control-label" data-bind="'attr':{'id':'registrant.' + name + 'Label', 'for':'customQuestion' + $index()}, 'html':question" id="registrant.251764196Label" for="customQuestion2">Which jurisdiction do you bill Medicare to?</label>
<!-- /ko -->
<!-- ko 'if': type == 'shortAnswer' --><!-- /ko -->
<!-- ko 'if': type == 'multipleChoice' -->
<select class="form-control maxCharLimit"
data-bind="'css':{'inputError': verificationFailed}, 'attr':{'id':'customQuestion' + $index(), tabindex:tabIdx},hasFocus:isSelected, options: answers, optionsText:'answer', optionsCaption:$parent.chooseOneText, value:selectedAnswer, optionsValue:'answerKey'"
id="customQuestion2" tabindex="13">
<option value="">Choose One...</option>
<option value="251764197">Jurisdiction K Part A, FQHC, HHH</option>
<option value="251764198">Jurisdiction K Part B</option>
<option value="251764199">Jurisdiction 6 Part A, FQHC, HHH</option>
<option value="251764200">Jurisdiction 6 Part B</option>
<option value="251764201">Other</option>
</select>
<!-- /ko -->
<span data-bind="visible:verificationFailed" class="help-block" style="display: none;"><i class="togo-icon togo-icon-error"></i><span data-bind="'text':errorMessage"></span></span>
</div>
</div>
<hr class="skinny">
<!-- /ko -->
<!-- ko 'if' : registrationQuestionsVM().commentsField --><!-- /ko -->
</div><!-- /ko -->
<div class="paymentBody" id="payment-form" data-bind="visible: showPayment" style="display: none;">
<!-- ko 'if' : registrationQuestionsVM().commentsField || registrationQuestionsVM().customQuestions().length == 0 --><!-- /ko -->
<div class="paymentFields" data-bind="visible: showCreditCardFields" style="display: none;">
<div clss="row">
<div class="card-disclaimer">
<i class="togo-icon togo-icon-lock-closed"></i>
<span class="stripe-text" data-i18n="registration.cardDisclaimer">Secured payments with your credit or debit card via stripe</span>
<span class="cards-icons">
<img src="../../../../images/visa.png">
<img src="../../../../images/masterCard.png">
<img src="../../../../images/amex.png">
<img src="../../../../images/discover.jpg">
</span>
</div>
<!-- Used to display form errors. -->
<div id="card-errors" role="alert"></div>
</div>
<div id="paymentBody-paymentRequest">
<!-- Stripe paymentRequestButton Element inserted here-->
</div>
<div class="row">
<div class="field card-number col-xs-12 col-sm-6 col-md-6 col-lg-6">
<label class="control-label" for="card-number" data-i18n="registration.creditCardNumber">Card Number</label>
<div id="card-number" class="field empty input payment-fields">
<!-- A Stripe Element will be inserted here. -->
</div>
</div>
<div class="field card-expiry col-xs-6 col-sm-3 col-md-3 col-lg-3">
<label class="control-label" for="card-expiry" data-i18n="registration.expirationDate">Expiration Date</label>
<div id="card-expiry" class="empty input payment-fields">
<!-- A Stripe Element will be inserted here. -->
</div>
</div>
<div class="field card-cvc col-xs-6 col-sm-3 col-md-3 col-lg-3">
<label class="control-label" for="card-cvc" data-i18n="registration.cvv">CVV</label>
<div id="card-cvc" class="empty input payment-fields">
<!-- A Stripe Element will be inserted here. -->
</div>
</div>
</div>
<div class="error" role="alert">
<svg xmlns="http://www.w3.org/2000/svg" width="17" height="17" viewBox="0 0 17 17">
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</form>Text Content
WELLNESS WEDNESDAY: SCREENING PELVIC EXAMS The email address you're registering with is already in use. Please register using an alternate email address. -------------------------------------------------------------------------------- This webinar meets 1 times. Wed, Aug 24, 2022 4:00 PM - 4:45 PM GMT Show in My Time Zone -------------------------------------------------------------------------------- Register today for the next Medicare-covered preventive service in our Wellness Wednesdays series! During this session will review the coverage, coding, and billing guidelines for this service. Attending this session will help ensure that your claims are submitted in accordance with the Medicare rules and regulations. -------------------------------------------------------------------------------- Required field First Name 128 Last Name 128 Email Address 128 Street Address 128 City 128 State/Province Choose One...NoneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto RicoVirgin IslandsGuamAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Zip/Postal Code 128 Phone Number 128 Organization 128 -------------------------------------------------------------------------------- Enter your provider number (PTAN/NPI) 128 Enter the compliance officer’s name and email 128 Which jurisdiction do you bill Medicare to? Choose One...Jurisdiction K Part A, FQHC, HHHJurisdiction K Part BJurisdiction 6 Part A, FQHC, HHHJurisdiction 6 Part BOther -------------------------------------------------------------------------------- Secured payments with your credit or debit card via stripe Card Number Expiration Date CVV Enter your card details Discount Code Apply Invalid discount code. Discount code applied successfully! NOTE: Please direct all payment-related questions to the webinar organizer. Your registration for this webinar is subject to GoTo’s Terms of Service and Privacy Policy. -------------------------------------------------------------------------------- Unfortunately your browser isn't supported. Please upgrade to Safari v7+ or switch to Chrome™ or FireFox®. By clicking this button, you submit your information to the webinar organizer, who will use it to communicate with you regarding this event and their other services. Register ©2022 GoTo, Inc. All rights reserved. View the GoTo Webinar Privacy Policy Firefox is a registered trademark of the Mozilla Foundation. To review the webinar organizer's privacy policy or opt out of their other communications, contact the webinar organizer directly. Safeguarding your email address and webinar registration information is taken seriously at GoTo Webinar. GoTo Webinar will not sell or rent this information.