REQUEST INFORMATION
If you would like to request information, receive our "You Can Stop Scams" folder or request a speaker to visit your organization and present on Medicare billing fraud issues, fill in this form.

YOUR INFORMATION
First Name:
Last Name:
Address:
City:
State:	(example IA)
ZIP:
Phone:
E-mail:
REGISTER
Would you like to receive updated info about current scams, educational opportunities and new prevention tips?
	Yes
WHAT DO YOU NEED?
Would you like us to mail you more information including a brochure, the "You Can Stop Scams" folder and a Senior Healthcare Guide to keep records of your service?
	Yes
Would you like to request a speaker to come visit you and explain how you can help protect your identity and decrease the amount of Medicare misplacements?
	Yes
If you checked "Yes" to request a speaker, please fill in the information below:
Event Date:	(example mm/dd/yyyy)
Event Location:
# Attending:	(Approximate # of People)
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