Target Coding

1245 Ginger Circle Weston, FL 33326 Toll Free: 800-270-7044 Tel: 954-389-9294 Fax: 954-389-3491 info@targetcoding.com

Target Codings One-Day On-Site Program Agreement 2

This program includes: A full day of training at your office for you and all employees. A comprehensive review of your CPT codes, ICD-9 codes, SOAP notes, Intake Forms, HIPAA Forms, Fee Schedules, Modifiers, Cash Plans, Insurance Verification Forms, Insurance EOBs and CMS-1500 Forms. Receive our guidebooks on The Best Diagnosis Codes to Improve Reimbursement and The Best CPT & ICD-9 Coding Combinations to Improve Reimbursement. 3-months of unlimited Q & A support. Submit your questions via telephone, fax or e-mail and get your answers within 24-48 hours. 3-months of unlimited access to all Target Coding webinars. The webinars are given just about every Tuesday and Thursday. The webinars are live, interactive and most are approved for CE credits in many states by New York Chiropractic College. The webinars are also available as an instant download for anytime viewing. Plus youll receive our monthly e-newsletter...stay up-to-date on the latest coding, billing compliance and documentation information. Cost: $2,900 (one payment) or 2 payments of $1,500.
Member Information: Name: ___________________________________________________________________ Address, City, State, Zip: Tel. #: _______________ ___________________________________________________________________ Fax #: _______________ Email: ____________________________

Credit Card Charges: Member authorizes Target Coding to charge the below credit card $2,900 (one payment) or 2 payments of $1,500 (30 days apart) for the services set forth in this agreement. Member is responsible to reimburse Target Coding for all travel & lodging expenses (i.e., airfare, hotel, car rental) associated with the on-site visit. If member reschedules or cancels this agreement, member is responsible to pay Target Coding for any travel & lodging cancellation/re-scheduling fees. Payment Method: Credit Card Number: Visa MasterCard AMEX

____________________________________________ Exp. Date: ___________________

Cardholder Signature: _____________________________________________ Sec. Code: ___________________ Credit Card Billing Address & Zip Code if different than above: __________________________________________

THE BELOW PARTIES HAVE EXECUTED THIS AGREEMENT FOR THE WRITTEN ABOVE. _______________________________
Target Coding Representative Signature

Dr. Marty Kotlar

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Member Signature

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