Please print this form using the proper browser commands. Complete the
information, then fax to:
770-993-0033
Your Name _____________________________________
Title ___________________________________________
Company _______________________________________
Address ________________________________________
Address ________________________________________
City ____________________ State _______ Zip _______
Telephone __________________________ E-Mail Address ______________________
Bill to (check one) ____Visa _____Mastercard _____Purchase Order
Account Name ___________________________________
Account Number ___________________________________
Expiration Date _____________________________________
PO Number _________________________________
Your Signature (required) __________________________________
Please check one of the following order options:
Publications ($19.95 each -- or order all five for $75.00)
______ How to Select a Physician for Your Medical Care Needs
______ How to Select the Correct Health Care Plan -- for Individuals
______ How to Select the Correct Health Care Plan -- for Employers
______ Managed Care Definitions
______ Managed Care Contractual Issues -- What to watch out for in managed care contracts
POSTAGE & HANDLING FREE -- All publications delivered via E-mail!
Please indicate preferred file format -- pick one
_____Microsoft Word 6.0 _____WordPerfect 7.0 _____ASCII
_____Adobe Acrobat _____HTML
TOTAL __________________
(Please hit the "Back" icon to return to AFHC)