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| 08.21.2008 at 07:15PM PDT, ID: 23669094 |
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index.cfm:
<cfif CGI.https is "Off">
<cflocation url="https://#cgi.server_name##cgi.script_name#?#cgi.query_string#" addtoken="no" />
</cfif>
<cfinclude template="/SiteHeaderSecure.cfm">
<!--- When the user submits the Form, she sees the information that she sent --->
<cfif IsDefined('RegistrationID')>
<!--- Display "success" message to user --->
<h2>Thank you for submitting your registration information for the ASC Association Audio Conference, Proposed Rule on ASC Medicare Rates. We will confirm your registration shortly.</h2>
<p>Upon receipt of registration, the ASC Association will send a confirmation via email with the toll-free dial-in number for the audio portion of the program and a web site link for you to access prior to the program. If you register for more than one webinar you will receive a separate confirmation for each conference. Your registration is valid for one telephone access line. Contact the Ambulatory Surgery Foundation at 703.836.5904 with any questions.</p>
<p>Here is the information you sent:</p>
<!--- set default values --->
<cfparam name="RegistrationID" default="">
<cfparam name="Greeting" default="">
<cfparam name="FirstName" default="">
<cfparam name="LastName" default="">
<cfparam name="Credentials" default="">
<cfparam name="Title" default="">
<cfparam name="FacilityCompany" default="">
<cfparam name="Address1" default="">
<cfparam name="Address2" default="">
<cfparam name="City" default="">
<cfparam name="State" default="">
<cfparam name="Zip" default="">
<cfparam name="Phone" default="">
<cfparam name="Fax" default="">
<cfparam name="Email" default="">
<cfparam name="TotalEnclosed" default="">
<cfparam name="FORM.AuthorizeCharge" default="">
<cfparam name="CreditCard" default="">
<cfparam name="CreditCardNumber" default="">
<cfparam name="ExpirationDate" default="">
<cfparam name="PrintedCardHolderName" default="">
<cfparam name="CreditCardZIPCode" default="">
<cfparam name="CVV" default="">
<cfparam name="DateCreated" default="">
<cfparam name="ReimbursementCycleChallengesMembers100" default="">
<cfparam name="ReimbursementCycleChallengesNonMembers150" default="">
<cfparam name="NewCodes2009Members100" default="">
<cfparam name="NewCodes2009NonMembers150" default="">
<cfparam name="OrthopedicCodingMembers100" default="">
<cfparam name="OrthopedicCodingNonMembers150" default="">
<cfparam name="Members50Discount" default="">
<cfoutput>
<p><strong>RegistrationID:</strong> #RegistrationID#</p>
<p><strong>Greeting:</strong> #Greeting#</p>
<p><strong>First Name:</strong> #FirstName#</p>
<p><strong>Last Name:</strong> #LastName#</p>
<p><strong>Credentials:</strong> #Credentials#</p>
<p><strong>Title:</strong> #Title#</p>
<CFIF FacilityCompany IS NOT ""><p><strong>Facility / Company:</strong> #FacilityCompany#</p></CFIF>
<p><strong>Address Line 1:</strong> #Address1#</p>
<CFIF Address2 IS NOT ""><p><strong>Address Line 2:</strong> #Address2#</p></CFIF>
<p><strong>City:</strong> #City#</p>
<p><strong>State:</strong> #State#</p>
<p><strong>Zip:</strong> #Zip#</p>
<p><strong>Phone:</strong> #Phone#</p>
<CFIF Fax IS NOT ""><p><strong>Fax:</strong> #Fax#</p></CFIF>
<p><strong>Email:</strong> #Email#</p>
<CFIF TotalEnclosed IS NOT ""><p><strong>Total Enclosed:</strong> #TotalEnclosed#</p></CFIF>
<CFIF AuthorizeCharge IS NOT ""><p><strong>Authorize Charge:</strong> #FORM.AuthorizeCharge#</p></CFIF>
<CFIF CreditCard IS NOT ""><p><strong>Credit Card:</strong> #CreditCard#</p></CFIF>
<CFIF CreditCardNumber IS NOT ""><p><strong>Credit Card Number:</strong> (Obscured for security)</p></CFIF>
<CFIF ExpirationDate IS NOT ""><p><strong>Expiration Date:</strong> (Obscured for security)</p></CFIF>
<CFIF PrintedCardHolderName IS NOT ""><p><strong>Printed Card Holder Name:</strong> #PrintedCardHolderName#</p></CFIF>
<CFIF CreditCardZIPCode IS NOT ""><p><strong>Credit Card ZIP Code:</strong> #CreditCardZIPCode#</p></CFIF>
<CFIF CVV IS NOT ""><p><strong>CVV:</strong> #CVV#</p></CFIF>
<p><strong>Date Submitted:</strong> #DateCreated#</p>
<CFIF ReimbursementCycleChallengesMembers100 IS NOT ""><p><strong>I registered for <em>Reimbursement Cycle Challenges and Practical Tips to Overcome</em> as a Member ($100)</strong> #FORM.ReimbursementCycleChallengesMembers100#</p></CFIF>
<CFIF ReimbursementCycleChallengesNonMembers150 IS NOT ""><p><strong>I registered for <em>Reimbursement Cycle Challenges and Practical Tips to Overcome</em> as a Non-Member ($150)</strong> #FORM.ReimbursementCycleChallengesNonMembers150#</p></CFIF>
<CFIF NewCodes2009Members100 IS NOT ""><p><strong>I registered for <em>New Codes for 2009: Hot Off the Press</em> as a Member ($100)</strong> #FORM.NewCodes2009Members100#</p></CFIF>
<CFIF NewCodes2009NonMembers150 IS NOT ""><p><strong>I registered for <em>New Codes for 2009: Hot Off the Press</em> as a Non-Member ($150)</strong> #FORM.NewCodes2009NonMembers150#</p></CFIF>
<CFIF OrthopedicCodingMembers100 IS NOT ""><p><strong>I registered for <em>Traps and Tips for Orthopedic and Pain Management Coding</em> as a Member ($100)</strong> #FORM.OrthopedicCodingMembers100#</p></CFIF>
<CFIF OrthopedicCodingNonMembers150 IS NOT ""><p><strong>I registered for <em>Traps and Tips for Orthopedic and Pain Management Coding</em> as a Non-Member ($150)</strong> #FORM.OrthopedicCodingNonMembers150#</p></CFIF>
<CFIF Members50Discount IS NOT ""><p>I am a member of the Ambulatory Surgery Foundation; I have registered for all three conferences by September 9th, 2008, and will receive a $50 discount off of my total.</strong> #FORM.Members50Discount#</p></CFIF>
</cfoutput>
<!--- Otherwise, display the form to user... --->
<cfelse>
<!--- A form to populate conference registration information in table ProposedRuleEntries --->
<cfform action="webinars2008_data_insert.cfm" enctype="multipart/form-data">
<h1>Get in Gear for 2009: Fall 2008 Business Office Tune Up Webinars</h1>
<h2>Special Audio - Web Conference Series</strong></h2>
<h3>Reimbursement Cycle Challenges and Practical Tips to Overcome
<div class="black"><strong>October 14, 2008</strong></div>
</h3>
<hr class="webform" />
<h3>New Codes for 2009: Hot Off the Press
<div class="black"><strong>November 18, 2008</strong></div></h3>
<hr class="webform" />
<h3>Traps and Tips for Orthopedic and Pain Management Coding
<div class="black"> <strong>December 16, 2008</strong> </div> </h3>
<hr class="webform" />
<h1>REGISTRATION INFORMATION</h1>
<table class="uvatable">
<tr><td class="uvatable-left"><strong>Greeting:</strong></td> <td class="uvatable-right"><cfinput TYPE="text" SIZE="30" NAME="Greeting" /></td></tr>
<tr><td class="uvatable-left"><strong>First Name:</strong></td> <td class="uvatable-right"><cfinput TYPE="text" SIZE="30" NAME="FirstName" /></td></tr>
<tr><td class="uvatable-left"><strong>Last Name:</strong></td> <td class="uvatable-right"><cfinput TYPE="text" SIZE="30" NAME="LastName" /></td></tr>
<tr><td class="uvatable-left"><strong>Credentials:</strong></td> <td class="uvatable-right"><cfinput TYPE="text" SIZE="30" NAME="Degree" /></td></tr>
<tr><td class="uvatable-left"><strong>Title:</strong></td> <td class="uvatable-right"><cfinput TYPE="text" SIZE="30" NAME="Title" /></td></tr>
<tr><td class="uvatable-left"><strong>Facility / Company:</strong></td> <td class="uvatable-right"><cfinput TYPE="text" SIZE="30" NAME="FacilityCompany" /></td></tr>
<tr><td class="uvatable-left"><strong>Address Line 1:</strong></td> <td class="uvatable-right"><cfinput TYPE="text" SIZE="30" NAME="Address1" /></td></tr>
<tr><td class="uvatable-left"><strong>Address Line 2:</strong></td> <td class="uvatable-right"><cfinput TYPE="text" SIZE="30" NAME="Address2" /></td></tr>
<tr><td class="uvatable-left"><strong>City:</strong></td> <td class="uvatable-right"><cfinput TYPE="text" SIZE="30" NAME="City" /></td></tr>
<tr><td class="uvatable-left"><strong>State:</strong></td> <td class="uvatable-right"><cfinput TYPE="text" SIZE="5" NAME="State" /></td></tr>
<tr><td class="uvatable-left"><strong>ZIP:</strong></td> <td class="uvatable-right"><cfinput TYPE="text" SIZE="5" NAME="Zip" /></td></tr>
<tr><td class="uvatable-left"><strong>Phone:</strong></td> <td class="uvatable-right"><cfinput TYPE="text" SIZE="20" NAME="Phone" /></td></tr>
<tr><td class="uvatable-left"><strong>Fax:</strong></td> <td class="uvatable-right"><cfinput TYPE="text" SIZE="20" NAME="Fax" /></td></tr>
<tr><td class="uvatable-left"><strong>Email:</strong></td> <td class="uvatable-right"><cfinput TYPE="text" SIZE="30" NAME="Email" /></td></tr>
</table>
<h1>REGISTRATION FEES</h1>
<table class="fasatableborder" width="100%">
<tr>
<td><h3>Fall 2008 Business Office Tune Up Webinars</h3></td>
<td valign="bottom"><strong>Members 100</strong></td>
<td valign="bottom"><strong>Non-Members 150</strong></td>
</tr>
<tr>
<td><strong>Reimbursement Cycle Challenges and Practical Tips to Overcome</strong>
<div class="red"><em>October 14, 2008</em></div> </td>
<td><cfinput type="Checkbox" name="ReimbursementCycleChallengesMembers100" class="noborder" /></td>
<td><cfinput type="Checkbox" name="ReimbursementCycleChallengesNonMembers150" class="noborder" /></td>
</tr>
<tr>
<td><strong>New Codes for 2009: Hot Off the Press</strong>
<div class="red"><em>November 18, 2008</em></div> </td>
<td><cfinput type="Checkbox" name="NewCodes2009Members100" class="noborder" /></td>
<td><cfinput type="Checkbox" name="NewCodes2009NonMembers150" class="noborder" /></td>
</tr>
<tr>
<td><strong>Traps and Tips for Orthopedic and Pain Management Coding</strong>
<div class="red"><em>December 16, 2008</em></div> </td>
<td><cfinput type="Checkbox" name="OrthopedicCodingMembers100" class="noborder" /></td>
<td><cfinput type="Checkbox" name="OrthopedicCodingNonMembers150" class="noborder" /></td>
</tr>
</table>
<p><cfinput type="Checkbox" name="Members50Discount" class="noborder" /> <strong>Members:</strong> Check here to register for all three conferences by September 9th, 2008, and receive a $50 discount off your total.</p>
<h1>PAYMENT INFORMATION</h1>
<p>To remit payment, you may print this registration form and fax or mail it to Ambulatory Surgery Foundation with a check. Or, submit your credit card information below. Credit card information is submitted through a secure connection, certified by SecureTrust.</p>
<div class="clear-both"></div>
<p class="float-left"><cfinput type="Checkbox" name="AuthorizeCharge" class="noborder" /> I authorize Ambulatory Surgery Foundation to charge my:</p>
<p class="float-right">
<select name="CreditCard" class="ChicagoSelect">
<option value="SelectCard">Select a Credit Card</option>
<option value="Visa">Visa</option>
<option value="MasterCard">MasterCard</option>
<option value="AmericanExpress">American Express</option></select></p>
<div class="clear-both"></div>
<table class="uvatable">
<tr>
<td>Credit Card Number:</td>
<td><cfinput TYPE="text" SIZE="30" NAME="CreditCardNumber" /></td>
<td>Expiration Date:</td>
<td><cfinput TYPE="text" SIZE="30" NAME="ExpirationDate" /></td>
</tr>
<tr>
<td>Printed Cardholder Name:</td>
<td><cfinput TYPE="text" SIZE="30" NAME="PrintedCardHolderName" /></td>
<td>Zip Code:</td>
<td><cfinput TYPE="text" SIZE="30" NAME="CreditCardZIPCode" /></td>
</tr>
<tr>
<td></td>
<td></td>
<td>CVV#/3-digit #:</td>
<td><cfinput TYPE="text" SIZE="30" NAME="CVV" /></td>
</tr>
<tr>
<td></td>
<td></td>
<td>Total Enclosed:</td>
<td> <cfinput TYPE="text" SIZE="30" NAME="TotalEnclosed" />
</td>
</tr>
</table>
<p><strong>Or:</strong> Call 703.836.5904 to register by phone</p>
<p><strong>Or:</strong> Print and fax this registration form with credit card information to 703.836.2090.</p>
<p>Upon receipt of registration, the ASC Association will send a confirmation via email with the toll-free dial-in number for the audio portion of the program and a web site link for you to access prior to the program. If you register for more than one webinar you will receive a separate confirmation for each conference. Your registration is valid for one telephone access line. Contact the Ambulatory Surgery Foundation at 703.836.5904 with any questions.</p>
<p class="align-center"><cfinput type="submit" name="submit" value="Submit Registration" /></p>
</cfform>
<!--- close CFIF --->
</cfif>
<h1>CONTINUING EDUCATION INFORMATION</h1>
<p><strong>AEUs</strong><br />
This program is approved for 4.5 hours of AEU credit by BASC Provider #3272.</p>
<p>This information will be used only in conjunction with Ambulatory Surgery Foundation and ASC Association business. We will not share your information with any other organizations.</p>
<hr />
<p class="float-left-img"><script type='text/javascript' src='https://sealserver.trustwave.com/seal.js?style=normal'></script></p>
<p>Transactions on this web page are secured by Trustwave. Click the Trustwave logo to the left to verify the security of this page.</p>
<cfinclude template="/SiteFooterSecure.cfm">
webinars2008_data_insert.cfm
<cfif isDefined('FORM.CheckEnclosed')>
<!--- checkbox has been checked and is present in post data --->
<cfset CheckEnclosed = 1>
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<cfset CheckEnclosed = 0>
<!--- checkbox not checked and not present --->
</cfif>
<cfif isDefined('FORM.AuthorizeCharge')>
<!--- checkbox has been checked and is present in post data --->
<cfset AuthorizeCharge = 1>
<cfelse>
<cfset AuthorizeCharge = 0>
<!--- checkbox not checked and not present --->
</cfif>
<strong></strong>
<!--- Insert values into database columns --->
<cfquery datasource="ebwebwork" dbname="ascassociation" name="createRegistration">
INSERT INTO Webinar2008Entries (
Greeting,
FirstName,
LastName,
Credentials,
Title,
FacilityCompany,
Address1,
Address2,
City,
State,
Zip,
Phone,
Fax,
Email,
TotalEnclosed,
AuthorizeCharge,
CreditCard,
CreditCardNumber,
ExpirationDate,
PrintedCardHolderName,
CreditCardZIPCode,
CVV,
DateCreated,
ReimbursementCycleChallengesMembers100,
ReimbursementCycleChallengesNonMembers150,
NewCodes2009Members100,
NewCodes2009NonMembers150,
OrthopedicCodingMembers100,
OrthopedicCodingNonMembers150,
Members50Discount)
VALUES(
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<cfqueryparam cfsqltype="cf_sql_varchar" value="#FirstName#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#LastName#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#Degree#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#Title#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#FacilityCompany#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#Address1#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#Address2#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#City#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#State#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#Zip#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#Phone#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#Fax#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#Email#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#TotalEnclosed#">,
<cfqueryparam cfsqltype="cf_sql_bit" value="#AuthorizeCharge#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#CreditCard#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#CreditCardNumber#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#ExpirationDate#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#PrintedCardHolderName#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#CreditCardZIPCode#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#CVV#">,
<cfqueryparam cfsqltype="cf_sql_timestamp" value="#now()#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#ReimbursementCycleChallengesMembers100#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#ReimbursementCycleChallengesNonMembers150#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#NewCodes2009Members100#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#NewCodes2009NonMembers150#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#OrthopedicCodingMembers100#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#OrthopedicCodingNonMembers150#">,
<cfqueryparam cfsqltype="cf_sql_varchar" value="#Members50Discount#">);
SELECT scope_identity() AS ident
</cfquery>
<!--- pass info back to previous page --->
<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">
<html>
<head>
<title>Registration Submitted</title>
</head>
<body onLoad="document.form.submit();">
<cfoutput>
<form name="form" method="post" action="/webinarsreg/index.cfm">
<!--- set value from newly created RegistrationID --->
<input type="hidden" name="RegistrationID" value="#createRegistration.ident#">
<!--- set rest of values from submitted form --->
<input type="hidden" name="Name" value="#FORM.Greeting#">
<input type="hidden" name="Name" value="#FORM.FirstName#">
<input type="hidden" name="Name" value="#FORM.LastName#">
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<input type="hidden" name="City" value="#FORM.City#">
<input type="hidden" name="State" value="#FORM.State#">
<input type="hidden" name="Zip" value="#FORM.Zip#">
<input type="hidden" name="Phone" value="#FORM.Phone#">
<input type="hidden" name="Fax" value="#FORM.Fax#">
<input type="hidden" name="Email" value="#FORM.Email#">
<input type="hidden" name="TotalEnclosed" value="#FORM.TotalEnclosed#">
<cfif isdefined("form.AuthorizeCharge")>
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<cfelse>
<input type="hidden" name="AuthorizeCharge" value="0">
</cfif>
<input type="hidden" name="CreditCard" value="#FORM.CreditCard#">
<input type="hidden" name="CreditCardNumber" value="#FORM.CreditCardNumber#">
<input type="hidden" name="ExpirationDate" value="#FORM.ExpirationDate#">
<input type="hidden" name="PrintedCardHolderName" value="#FORM.PrintedCardHolderName#">
<input type="hidden" name="CreditCardZIPCode" value="#FORM.CreditCardZIPCode#">
<input type="hidden" name="CVV" value="#FORM.CVV#">
<cfif isdefined("form.ReimbursementCycleChallengesMembers100")>
<input type="hidden" name="ReimbursementCycleChallengesMembers100" value="#FORM.ReimbursementCycleChallengesMembers100#">
<cfelse>
<input type="hidden" name="ReimbursementCycleChallengesMembers100" value="0">
</cfif>
<cfif isdefined("form.ReimbursementCycleChallengesNonMembers150")>
<input type="hidden" name="ReimbursementCycleChallengesNonMembers150" value="#FORM.ReimbursementCycleChallengesNonMembers150#">
<cfelse>
<input type="hidden" name="ReimbursementCycleChallengesNonMembers150" value="0">
</cfif>
<cfif isdefined("form.NewCodes2009Members100")>
<input type="hidden" name="NewCodes2009Members100" value="#FORM.NewCodes2009Members100#">
<cfelse>
<input type="hidden" name="NewCodes2009Members100" value="0">
</cfif>
<cfif isdefined("form.NewCodes2009NonMembers150")>
<input type="hidden" name="NewCodes2009NonMembers150" value="#FORM.NewCodes2009NonMembers150#">
<cfelse>
<input type="hidden" name="NewCodes2009NonMembers150" value="0">
</cfif>
<cfif isdefined("form.OrthopedicCodingMembers100")>
<input type="hidden" name="OrthopedicCodingMembers100" value="#FORM.OrthopedicCodingMembers100#">
<cfelse>
<input type="hidden" name="OrthopedicCodingMembers100" value="0">
</cfif>
<cfif isdefined("form.OrthopedicCodingNonMembers150")>
<input type="hidden" name="OrthopedicCodingNonMembers150" value="#FORM.OrthopedicCodingNonMembers150#">
<cfelse>
<input type="hidden" name="OrthopedicCodingNonMembers150" value="0">
</cfif>
<cfif isdefined("form.Members50Discount")>
<input type="hidden" name="Members50Discount" value="#FORM.Members50Discount#">
<cfelse>
<input type="hidden" name="Members50Discount" value="0">
</cfif>
<input type="hidden" name="DateCreated" value="#DateFormat(now(), "mm/dd/yyyy")#">
</form>
</cfoutput>
</body>
</html>
|