Annual Convention Attendee Registration

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Annual Convention Attendee Registration

Name *

Phone Number *

Email Address *

Address *

Address

Address

Address

City

City

State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

State/Province

Zip/Postal

Zip/Postal

Organization *

Title *

Exclusive WiFi Sponsor Second Complimentary Attendee

First Name *

Last Name *

Title *

Email *

Membership Type

Are You a Health Plan Member or Affiliate Member? * Yes No

Which Health Plan or Affiliate Member? * Aetna, Inc. AmeriHealth Caritas Anthem BlueCross/BlueShield AudioNet America, Inc. AultCare Avesis / The Guardian Life Insurance Co. of America Buckeye Health Plan CareSource Cigna Healthcare Delta Dental Plan of Ohio DentaQuest Humana Medical Mutual of Ohio Molina Healthcare of Ohio, Inc. Navitus Health Solutions OSU Health Plan, Inc. Paramount Health Care SummaCare, Inc. The Health Plan UnitedHealthcare Community Plan UnitedHealthcare of Ohio Versant Health

Health Plan Member Registration Type * Member Health Plan or Affiliate- $300 Member Reserved Table- $1850

Are You a Supporting Member? * Yes No

Which Supporting Member? * AbbVie Access2Care Ameridial, Inc. Apellis Pharmaceuticals, Inc. AstraZeneca Bayer HealthCare Biogen, Inc. CAQH CareAdvisors Genentech Gilead Sciences Health Management Associates (HMA) Jefferson Health Plan Joint Academy, Inc. Little Hercules Foundation Magellan Health Medline Industries Merck & Co. New Century Health Novartis Services Novo Nordisk Orexo Pharmaceuticals Provide A Ride Sarepta Therapeutics Sellers Dorsey & Associates, LLC Squire Patton Boggs Sun Pharma Thrive Behavioral Health Center UCB Pharma VaxCare LLC Verrica Pharmaceuticals Vertex Pharmaceuticals

Has Your Organization Already Registered As A Sponsor? * Yes No

Supporting Member Registration Type: * Complimentary (two per supporting member) Additional Supporting Member (complimentary registrations already used)- $750

Company Name Registered As Sponsor * Abbvie AMERIDIAL, INC. AstraZeneca CarePort Health EPIC Insurance Brokers & Consultants FirstLine Medical Healthify Inovalon Little Hercules Foundation LogistiCare Circulation Magellan Health MedImpact Merck & Co. Mom's Meals Navitus Health Solutions New Century Health Philips Healthcare, N.A. Propeller Health Quest Analytics SafeRide Health Shield HealthCare Smith & Nephew Sunovion Pharmaceuticals Inc. Sun Pharma Takeda Pharmaceuticals The Guardian Life Insurance Company of America ZOLL Services Inc. - LifeVest

Additional Sponsor Opportunity Selected

Registration Type * Other Attendee $750

Supporting Member Second Complimentary Attendee Information

First Name *

Last Name *

Title *

Email *

Table Guests

1. First Name

Last Name

Title

Email

2. First Name

Last Name

Title

Email

3. First Name

Last Name

Title

Email

4. First Name

Last Name

Title

Email

5. First Name

Last Name

Title

Email

6. First Name

Last Name

Title

Email

7. First Name

Last Name

Title

Email

Additional Registrants

Add Another? * Yes No

1. First Name *

1. Last Name *

1. Title *

1. Email Address *

Amount *

Amount *

Amount *

Add Second? * Yes No

2. First Name *

2. Last Name *

2. Title *

2. Email Address *

Amount *

Amount *

Amount *

Add Third? * Yes No

3. First Name *

3. Last Name *

3. Title *

3. Email Address *

Amount *

Amount *

Amount *

Add Fourth? * Yes No

4. First Name *

4. Last Name *

4. Title *

4. Email Address *

Amount *

Amount *

Amount *

Add Fifth? * Yes No

5. First Name *

5. Last Name *

5. Title *

5. Email Address *

Amount *

Amount *

Amount *

Add Sixth? * Yes No

6. First Name *

6. Last Name *

6. Title *

6. Email Address *

Amount *

Amount *

Amount *

Dietary Needs

Dietary Needs: (Please note any allergies or dietary restrictions)

Payment

Registration Fee Amount

Payment Method *

Check (Mail to: OAHP, 20 E. Broad Street, Suite 701, Columbus, OH 43215. Your registration will not be processed until we receive payment.)

PayPal / Credit or Debit Card

All cancellations must be received in writing to the OAHP by September 24, 2021, less a $100 service charge to receive a refund and approval of cancellation. No cancellations will be accepted, or refunds issued after this date. Substitutions are accepted and encouraged.

Contract will not be processed without payment and contract authorization unless other arrangements have been made through OAHP.

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