| Name and Address |
| First Name: |
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| Last Name: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Contact Information |
| Daytime Phone:: |
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| Evening Phone: |
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| Email |
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| Educational/Vocational Background |
| Coding Experience: |
None |
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Intermediate |
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Advanced |
| Type of Coding Experience: |
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| Length of Time: |
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| Specialty: |
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| Knowledge of Medical Terminology |
None |
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Intermediate |
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Advanced |
| Name of Class or Job Experience/Training: |
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| Knowledge of Anatomy and Physiology |
None |
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Intermediate |
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Advanced |
| Class Format Preference |
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Weekday Evenings twice a week |
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Saturday Morning (4 hours) |
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Saturday Afternoon (4 hours) |
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All day Saturday (8 hours) |
| Would you be interested in M-F 8:00 AM to 4:00 PM class?: |
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| Is AAPC certification your goal?: |
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