Enrollment Form

Before filling out the enrollment form please follow this link and ensure that you have read and understand the contents.

Payments are also due at the time of enrollment. Once the enrollment form is submitted students will be taken to the payment screen.

Enrollment forms submitted without payment will not be processed.

Individuals who have submitted an enrollment form without payment will need to re-submit a new enrollment form with the payment in order to be processed.

Class seats are reserved once the enrolment form has been processed. Forms are processed according to their submission & payment date.

Please note that all fields followed by an asterisk must be filled in. First Name* First Name* Last Name* Last Name* E-mail Address* E-mail Address* State/Prov* State/Prov* Country* Country* Country United States Canada ---------------- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribadi North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Federated States of Micronesia Moldova Monaco Mongolia Monserrat Morocco Montenegro Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda S. Georgia and S. Sandwich Isls. Saint Kitts and Nevis Saint Lucia Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam US VIrgin Islands Wallis and Futuna Islands Western Sahara Yemen Yugoslavia (former) Zaire Zambia Zimbabwe Home Phone* Home Phone* Education* Education* High School Diploma/GED Certificate Course Associate's Bachelor's Master's Higher Education None of the Above Coding Experience* Coding Experience* No Experience/New to Field Familiar with Basics 1-2 years Experience 3-5 year Experience More than 5 years Experience Other Experience / Comments Have you ever taken a billing or coding course before?* Have you ever taken a billing or coding course before?* Yes No Do you know Medical Terminology?* Do you know Medical Terminology?* Yes No Do you know Gross Anatomy?* Do you know Gross Anatomy?* Yes No How do you rate your computer abilities?* How do you rate your computer abilities?* Basic Intermediate Above Average Excellent Do you own or have access to a reliable computer?* Do you own or have access to a reliable computer?* Yes No By checking this box I am agreeing that I have read and understand the system and cost requirements and have read and understand the payment and reimbursment policies.* By checking this box I am agreeing that I have read and understand the system and cost requirements and have read and understand the payment and reimbursment policies.* I have read and agree Please enter the word that you see below.