Order Form

Payment Information
Credit Card #: __________________________
Expiration Date: ____/ ____/  (mm/YY)
Cardholder's name: _____________________
CVV or CVC: _____________________________
Signature : ______________________________
Billing Info : ____________________________

Visa    MasterCard    Discover   
American Express   
Others (Type Here)   _________________

Personal Information
Name: _____________________________________
Address: ___________________________________
Address Line 2: ____________________________
City: _______________________________________
State: ______________________________________
ZIP: ________________________________________
Phone: _____________________________________
Fax: ________________________________________
Email: ______________________________________
Job title*: _________________________________

Fill out the order form, and revert back at: cs@healthcareworlds.com

Conference Title: Stop Huge Penalties for Innocent Balanced Billing Law Violations
Conference Date: Jan 22, 2026 
Quantity Price Total
Live Session $179
Recording $199
Digital Download $249
Transcript (PDF) $199
Corporate Live 1-10-Attendees $999
Live+Recording $349
Recording+Transcript $299
Digital Download+Transcript $349
Coupon Code
Total
Please send the completed order form via fax or e-mail
Note: All the order related material (Presentation, Transcript etc.) shall be fulfilled through the included email address only.

For any queries call at +1 844-445-3653 or email at hello@fulfillmentatoz.com