Online Enrollment

Approved and Regulated by the
Colorado Department of Higher Education,
Private Occupational School Board.

Please Note: This enrollment form is for STUDENTS NEW to Career Coders Online Campus. If you are already enrolled, are taking classes, or have taken class online, do NOT use this form. Instead, please call the office to take additional classes: 970-663-0020.

* = Required Field

The following information is used for billing and identification only and will not be sold or used for any solicitation. Your information is secured by HIPAA privacy policies.

Student Information
*First Name
*Last Name
*Street Address
Additional Address (e.g., Apt. No.)
*City
*State
*Zip
*Email Address
You must have an email address—Your email will be used for online access, correspondence, and classroom communication only.
*Home Phone	() -
Cell Phone	() -
Work Phone	() -
*Preferred Method of Contact
*Your Time Zone
MyCareerCoders Information (Online Access)
Your User Name will be your email address. Please select a password for your Online Access:
*Password
*Password Confirm

Program/Courses (Check all that apply)
*Please check all classes you are registering for. These are in the recommended order of class completion.
1.		Basic Anatomy and Medical Terminology 10 weeks. Tuition: $900.00 + Books Prerequisite: None
2.		Introduction to Medical Billing and Coding 10 weeks. Tuition: $1800.00 + Books Prerequisite: None, Medical Terminology and Anatomy recommended but not required.
3.		CPC Certification Class 10 weeks. Tuition: $1800.00 + Book (tuition does not include fees for AAPC national test or AAPC membership) Prerequisite: Medical Terminology, Anatomy, Proficient in CPT, ICD-9, HCPCS, Modifiers, Medicare Rules and Regulations, Coding Concepts, HIPAA, High School Diploma
Payment Method (How will you be paying?)
Registration/Payments must be received 10 days prior* to class start date
Check Cash Credit Card Student Loan Work Force/Gov Program Other
Payments made to: Career Coders, LLC, 292 Marcy Drive, Loveland, CO 80537

Credit Card Information (required if paying by credit card)
ONLY MasterCard/Visa Accepted—Career Coders, LLC will charge your card for the total of the courses selected above.
*Type of Credit Card
*Credit Card Number (no spaces)
*Expiration Date
*Security Code (3-digit no. on back)
Cardholder Billing Address
*Street Address
*City
*State
*Zip
*Name as it appears on the card
Consent
I have read and agree to submit (sign and FAX or mail prior to the start of classes) the following: Form B: Student Assessment/Evaluation/Policies CPC Class Assessment (if taking PMCC CPC class) I fully understand and agree with the terms of the Enrollment Agreement by providing the information above and clicking the submit button below.

Dedicated to making positive changes in your life and career.

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