SlideShare una empresa de Scribd logo
1 de 4
Descargar para leer sin conexión
Mary P. Griskewicz,
Healthcare Information
and Management Systems
Society (HIMSS)
Patrick M. Hamilton,
Centers for Medicare &
Medicaid Services (CMS)
Thomas Novak, Office of
the National Coordinator
for Health IT (ONC)
Hailey Schepp, Sanford
Health
Lisa S. Stump, Yale New
Haven Health
Media Partners &
Supporters:
www.MeaningfulUseAuditandComplianceConference.com
Email: info@ghpnetwork.comA Division of IQPC Healthcare Inc.
July 27 & 28, 2015, Sheraton Society Hill Hotel, Philadelphia, PA
Navigate Stage 2 attestation & avoid penalties under Stage 3 regulation
  












Conference Highlights:
•	First Hand Experience
with CMS Meaningful
Use Audits
•	Improved Patient Care
and other Non-Financial
Benefits to EHR Systems
Speakers Include:
Christine
VanZandbergen, Penn
Medicine Information
Services
Karen A. Packard,
MaineHealth
Stephanie Battista,
MedStar Health
Anita Somplasky, Quality
Insights Pennsylvania
Antonio Vega, Telligen
Balavignesh
Thirumalainambi, New
Jersey Health Information
Technology Extension
Center (NJ-HITEC)
Lisa Rosenberger,
National Opinion
Research Center (NORC)
Gena Fouke, Hayes
Management Consulting
James B. Wieland,
Ober | Kaler
Daniel F. Gottlieb,
McDermott Will & Emery
•	Meaningful Use Stage
3 Roll Out - Program
Changes & New
Requirements
•	Sustaining an EHR
System – Cost/Benefit
Analysis
•	Successfully Navigating
the CMS Audit Landscape
•	HIT Plugged In:
A Case for Health IT
Management
To register please visit www.MeaningfulUseAuditandComplianceConference.com
8:30 	 Registration & Complimentary Breakfast
9:00 	 Opening Remarks from GHP Network
	 Brandy Baker, Program Research Director, GHP Network
9:05 	 Opening Remarks from Conference Chair
	 Thomas Novak, Director of Delivery System Reform, Office
of Provider and Adoption Support, Office of the National
Coordinator for Health IT
9:10 	 KEYNOTE ADDRESS: Achieve Meaning from
the Meaningful Use of EHRs: Stage 1 and
Beyond
	 Review the history and true intent of the EHR Meaningful Use
program
·· Understand the progress on the program through today
·· Look at the proposed rule for Stage 3, the final stage of the
Meaningful Use program
	 Mary P. Griskewicz, MS, FHIMSS, Senior Director, Healthcare
Information Systems, Healthcare Information and
Management Systems Society
9:50 	 EHR Incentive Programs Overview
·· Provide an update on the latest participation data for the EHR
Incentive Program
·· Explain broadly the goals of the EHR Incentive Programs
·· Discuss incentive payments, payment adjustments, and audits
	 Patrick M. Hamilton, Health Insurance Specialist/Rural Health
Coordinator, U.S. Department of Health & Human Services,
Centers for Medicare & Medicaid Services Philadelphia
Regional Office
10:30	 Morning Break: Tea & Refreshments
11:00	 Stage 3 of Meaningful Use and the ONC
Roadmap to Interoperability
·· Providing more flexibility for providers and simplifying
requirements
·· Supporting interoperability and the adoption of EHRs
·· Improving outcomes for patients
	 Thomas Novak, Director of Delivery System Reform, Office
of Provider and Adoption Support, Office of the National
Coordinator for Health IT
11:40 	 Sanford Health: Successfully Attesting to
Stage 2 and Pro-actively Planning for Stage 3
	 Hailey Schepp, MPA, Director of Meaningful Use, Sanford
Health
12:20 	 Lunch Break
1:20 	 Benefits of EHR Systems – Beyond Meaningful
Use Incentives
·· Explanation of Epic system at YNHH and our next steps
·· Leveraging Health IT across the continuum
·· Driving improved quality, safety and lower costs
	 Lisa S. Stump, MS, RPh, FASHP, Vice President, Associate Chief
Information Officer, Yale New Haven Health
2:00 	 Health IT Workforce Development: A Return on
Investment
·· Variability in workforce needs depending on setting, location
and other factors
·· Variability in the backgrounds of employees has a large effect
on their success	
·· Health IT workforce needs are constantly evolving
	 Lisa Rosenberger, MPH, Research Scientist, National Opinion
Research Center at the University of Chicago
2:40 	 Afternoon Break: Tea & Refreshments
3:10	 EHR Selection, Implementation & Sustainability
for Critical Access Hospitals
·· Discuss best practices for selecting and implementing
electronic health records
·· How to set an actionable plan to sustain a Meaningful Use
Program
·· A look at some of the barriers involved with Critical Access
Hospitals to sustaining and implementing a Meaningful Use
Program
	 Antonio Vega, Health Information Technology Advisor, Telligen
3:50	 PANEL DISCUSSION: Meaningful Use - What
Stage 3 Means for the Future
·· Changes in the Meaningful Use Program for Eligible Hospitals
·· Planning to meet new requirements
·· Avoiding penalties in 2018 and planning for the future
	Moderator:
Balavignesh Thirumalainambi, MS, MBA, CPHIMS, CHTS-
CP, Meaningful Use Director, New Jersey Health Information
Technology Extension Center
	Panelists:
Christine VanZandbergen, MPH, PA-C, Associate CIO Clinical
Applications, Penn Medicine Information Services
	 Lisa S. Stump, MS, RPh, FASHP, Vice President, Associate Chief
Information Officer, Yale New Haven Health
	 Hailey Schepp, MPA, Director of Meaningful Use, Sanford Health
4:50 	 Close of Day One from Conference Chair
	 Thomas Novak, Director of Delivery System Reform, Office
of Provider and Adoption Support, Office of the National
Coordinator for Health IT
5:00	 Happy Hour: GHP invites all speakers and
delegates to discuss the day’s presentations at
the informal networking drinks reception
For exclusive insights on future GHP Network programs visit us at www.ghpnetwork.com or join us on social media.
DAY ONE: Monday, July 27, 2015
DAY TWO: Tuesday, July 28, 2015
OTHER UPCOMING EVENTS
To register please visit www.MeaningfulUseAuditandComplianceConference.com
June 29th and 30th, 2015
Orlando, FL
July 23rd and 24th, 2015
Chicago, IL
July 29-31, 2015
Austin, TX
8:30 	 Complimentary Breakfast & Networking
9:00 	 Opening Remarks from Conference Chair
	 Thomas Novak, Director of Delivery System Reform, Office
of Provider and Adoption Support, Office of the National
Coordinator for Health IT
9:10 	 Mitigating the Risks of an Audit
·· Issues to consider in order to be prepared for a potential audit
·· How to fine-tune the response to an audit request, depending on
the source of the audit and its subject
·· Three potential strategies for dealing with an attestation issue
that is discovered prior to an audit, potentially avoiding the need
to withdraw and refund
	 James B. Wieland, Principal, Ober | Kaler
9:50 	 Mock Audits: Preparing for a CMS Audit
·· Preventing recoupment by thinking like an auditor
·· Operational: finding data, organizing evidence, developing
checklists
·· Quality and improvement should always be the end goal
	 Karen A. Packard, MS, Program Manager, Meaningful Use,
Information Systems, MaineHealth	
	 Gena Fouke, RHIT, BSBA, Meaningful Use Consultant, Hayes
Management Consulting
10:30 	 Morning Break: Tea & Refreshments
11:00 	 OIG and Figliozzi Meaningful Use Audits
·· Understand the differences between meaningful use audits
conducted by Figliozzi and the U.S. Department of Health and
Human Services Office of Inspector General (OIG), including,
without limitation, the extent to which incentive payments are at
risk under each audit
·· Understand how to maintain appropriate documentation of
meaningful use, including, without limitation, requirements for
a security risk assessment under the protecting electronic health
information core measure
·· Learn how to develop an effective response to meaningful use
auditors
·· Understand the path from audit to appeal
	 Daniel F. Gottlieb, Esq., Partner, McDermott Will & Emery
11:40 	 How to Survive Multi-Facility MU Audits
·· Identify processes and timelines preparing for a CMS audit
·· Identify key organizational strategies for audit preparation
·· Identify documents required for an audit
	 Stephanie Battista, RN BSN, Meaningful Use Analyst and Program
Coordinator, MedStar Health
12:20 	 Lunch Break
1:20 	 "Meaningful" Use of EHR Technology to Improve
Patient Outcomes
·· Understand how native EMR functionality can improve
communication between care teams and patients
·· Understand how an automated, real time IT intervention can
help care teams recognize and intervene on critical, resulting in
improved outcomes
·· Understand how to leverage existing data in electronic health
records to create custom tools to support patient care
	 Christine VanZandbergen, MPH, PA-C, Associate CIO Clinical
Applications, Penn Medicine Information Services
2:00 	 PANEL DISCUSSION: HIT for Improved Healthcare
Quality, Efficiency & Safety
·· Leveraging HIT to improve outcomes
·· Determine how “meaningful” EHR MU data is
·· Ensuring patient safety with effective use of Health IT
	Moderator:
	 Thomas Novak, Director of Delivery System Reform, Office
of Provider and Adoption Support, Office of the National
Coordinator for Health IT
	Panelists:
	 Balavignesh Thirumalainambi, MS, MBA, CPHIMS, CHTS -
CP, Meaningful Use Director, New Jersey Health Information
Technology Extension Center
	 Anita Somplasky, RN CHTS-CP, CHTS-PW, Director of Quality
Measure and Regional Extension Center Initiatives, Quality
Insights of Pennsylvania
	 Antonio Vega, Health Information Technology Advisor, Telligen
3:00 	 Close of Meaningful Use Audit and Compliance
Conference from Conference Chair
	 Thomas Novak, Director of Delivery System Reform, Office
of Provider and Adoption Support, Office of the National
Coordinator for Health IT
facebook.com/ghpnetworkus twitter.com/ghpnetwork linkedin.com/company/ghp-network
A Division of IQPC Healthcare Inc.
Package
Early Bird:
Register and pay
by June 5, 2015
Standard Rate:
Register and pay by
July 3, 2015
Late Rate: Register and pay
after July 3, 2015
CONFERENCE ONLY
(July 27-28)
USD $1495 USD $1695 USD $1895
Yes, please register me for:
Please note:
•	 All ‘Early Bird’ discounts require payment at time of registration and before the cut-off date in order to receive any discount.
•	 Please view our registration policy for full information about payment, cancellation, postponement,substitution and discounts.
•	 Please note multiple discounts cannot be combined
❏ Conference
Conference Venue
A $99 processing charge will be assessed to all
registrations not accompanied by credit card
payment at the time of registration.
MAKE CHECKS PAYABLE IN US DOLLARS TO:
IQPC HEALTHCARE, INC
Details for making payment via EFT or wire
transfer:
JPMorgan Chase
Penton Learning Systems LLC dba
ABA/Routing #: 021000021
Reference: IQPC: 25458.001
IQPC
535 5th Avenue, 8th
Floor New York, NY 10017
Attn: Terence Wu
Phone: 646-378-6021
Payment Policy: Payment is due in full at the
time of registration and includes lunches and
refreshment.
Your registration will not be confirmed until
payment is received and may be subject to
cancellation.
For IQPC’s Cancellation, Postponement and
Substitution Policy, please visit www.iqpc.com/
cancellation
©2015 IQPC. All Rights Reserved. The format,
design, content and arrangement of this brochure
constitute a trademark of IQPC. Unauthorized
reproduction will be actionable under the Lanham
Act and common law principles
Please note: GHP Network will never
recommend, approve or appoint any third party
rooming service to act on our behalf. Please be
extremely wary if you are approached by any
such companies. We will always endeavor to
negotiate the best available rates for you so
please use the Hotel´s website link provided.
MAC CODE
MAIL
Registration Details
EASY WAYS
TO REGISTER:
www.MeaningfulUseAuditandComplianceConference.com
Call: 1-800-882-8684
EMAIL: info@GHPNetwork.com
FAX: 1-646-378-60254
Sheraton Philadelphia Society
Hill Hotel
1 Dock St
Philadelphia, PA 19106
(215) 238-6000
For Reservations please visit:
www.sheratonphiladelphiasocietyhill.com
www.meaningfuluseauditandcomplianceconference.com
Email: info@ghpnetwork.com
Attendee Information:
Name: _________________________________________________________________________________________
Company: _____________________________________________________________________________________
Phone: _______________________________ Email: ___________________________________________________
Special Dietary Needs: If you have a dietary restriction, please contact Customer Service at 1-800-882-8684 to
discuss your specific needs.
Payment Information:
q Visa 	 q MasterCard 	 q American Express 	q Discover
Credit Card Number: ____________________________________________________________________________
Expiration Date: _______/_______/_______ Security Code: ____________
Card Holder’s Name: ____________________________________________________________________________
Signature: _____________________________________________________________________________________
Billing Address on Card: __________________________________________________________________________
_______________________________________________________________________________________________
JMUJICA

Más contenido relacionado

MeaningfulUseAuditAndCompliance_JMUJICA

  • 1. Mary P. Griskewicz, Healthcare Information and Management Systems Society (HIMSS) Patrick M. Hamilton, Centers for Medicare & Medicaid Services (CMS) Thomas Novak, Office of the National Coordinator for Health IT (ONC) Hailey Schepp, Sanford Health Lisa S. Stump, Yale New Haven Health Media Partners & Supporters: www.MeaningfulUseAuditandComplianceConference.com Email: info@ghpnetwork.comA Division of IQPC Healthcare Inc. July 27 & 28, 2015, Sheraton Society Hill Hotel, Philadelphia, PA Navigate Stage 2 attestation & avoid penalties under Stage 3 regulation                Conference Highlights: • First Hand Experience with CMS Meaningful Use Audits • Improved Patient Care and other Non-Financial Benefits to EHR Systems Speakers Include: Christine VanZandbergen, Penn Medicine Information Services Karen A. Packard, MaineHealth Stephanie Battista, MedStar Health Anita Somplasky, Quality Insights Pennsylvania Antonio Vega, Telligen Balavignesh Thirumalainambi, New Jersey Health Information Technology Extension Center (NJ-HITEC) Lisa Rosenberger, National Opinion Research Center (NORC) Gena Fouke, Hayes Management Consulting James B. Wieland, Ober | Kaler Daniel F. Gottlieb, McDermott Will & Emery • Meaningful Use Stage 3 Roll Out - Program Changes & New Requirements • Sustaining an EHR System – Cost/Benefit Analysis • Successfully Navigating the CMS Audit Landscape • HIT Plugged In: A Case for Health IT Management
  • 2. To register please visit www.MeaningfulUseAuditandComplianceConference.com 8:30 Registration & Complimentary Breakfast 9:00 Opening Remarks from GHP Network Brandy Baker, Program Research Director, GHP Network 9:05 Opening Remarks from Conference Chair Thomas Novak, Director of Delivery System Reform, Office of Provider and Adoption Support, Office of the National Coordinator for Health IT 9:10 KEYNOTE ADDRESS: Achieve Meaning from the Meaningful Use of EHRs: Stage 1 and Beyond Review the history and true intent of the EHR Meaningful Use program ·· Understand the progress on the program through today ·· Look at the proposed rule for Stage 3, the final stage of the Meaningful Use program Mary P. Griskewicz, MS, FHIMSS, Senior Director, Healthcare Information Systems, Healthcare Information and Management Systems Society 9:50 EHR Incentive Programs Overview ·· Provide an update on the latest participation data for the EHR Incentive Program ·· Explain broadly the goals of the EHR Incentive Programs ·· Discuss incentive payments, payment adjustments, and audits Patrick M. Hamilton, Health Insurance Specialist/Rural Health Coordinator, U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services Philadelphia Regional Office 10:30 Morning Break: Tea & Refreshments 11:00 Stage 3 of Meaningful Use and the ONC Roadmap to Interoperability ·· Providing more flexibility for providers and simplifying requirements ·· Supporting interoperability and the adoption of EHRs ·· Improving outcomes for patients Thomas Novak, Director of Delivery System Reform, Office of Provider and Adoption Support, Office of the National Coordinator for Health IT 11:40 Sanford Health: Successfully Attesting to Stage 2 and Pro-actively Planning for Stage 3 Hailey Schepp, MPA, Director of Meaningful Use, Sanford Health 12:20 Lunch Break 1:20 Benefits of EHR Systems – Beyond Meaningful Use Incentives ·· Explanation of Epic system at YNHH and our next steps ·· Leveraging Health IT across the continuum ·· Driving improved quality, safety and lower costs Lisa S. Stump, MS, RPh, FASHP, Vice President, Associate Chief Information Officer, Yale New Haven Health 2:00 Health IT Workforce Development: A Return on Investment ·· Variability in workforce needs depending on setting, location and other factors ·· Variability in the backgrounds of employees has a large effect on their success ·· Health IT workforce needs are constantly evolving Lisa Rosenberger, MPH, Research Scientist, National Opinion Research Center at the University of Chicago 2:40 Afternoon Break: Tea & Refreshments 3:10 EHR Selection, Implementation & Sustainability for Critical Access Hospitals ·· Discuss best practices for selecting and implementing electronic health records ·· How to set an actionable plan to sustain a Meaningful Use Program ·· A look at some of the barriers involved with Critical Access Hospitals to sustaining and implementing a Meaningful Use Program Antonio Vega, Health Information Technology Advisor, Telligen 3:50 PANEL DISCUSSION: Meaningful Use - What Stage 3 Means for the Future ·· Changes in the Meaningful Use Program for Eligible Hospitals ·· Planning to meet new requirements ·· Avoiding penalties in 2018 and planning for the future Moderator: Balavignesh Thirumalainambi, MS, MBA, CPHIMS, CHTS- CP, Meaningful Use Director, New Jersey Health Information Technology Extension Center Panelists: Christine VanZandbergen, MPH, PA-C, Associate CIO Clinical Applications, Penn Medicine Information Services Lisa S. Stump, MS, RPh, FASHP, Vice President, Associate Chief Information Officer, Yale New Haven Health Hailey Schepp, MPA, Director of Meaningful Use, Sanford Health 4:50 Close of Day One from Conference Chair Thomas Novak, Director of Delivery System Reform, Office of Provider and Adoption Support, Office of the National Coordinator for Health IT 5:00 Happy Hour: GHP invites all speakers and delegates to discuss the day’s presentations at the informal networking drinks reception For exclusive insights on future GHP Network programs visit us at www.ghpnetwork.com or join us on social media. DAY ONE: Monday, July 27, 2015
  • 3. DAY TWO: Tuesday, July 28, 2015 OTHER UPCOMING EVENTS To register please visit www.MeaningfulUseAuditandComplianceConference.com June 29th and 30th, 2015 Orlando, FL July 23rd and 24th, 2015 Chicago, IL July 29-31, 2015 Austin, TX 8:30 Complimentary Breakfast & Networking 9:00 Opening Remarks from Conference Chair Thomas Novak, Director of Delivery System Reform, Office of Provider and Adoption Support, Office of the National Coordinator for Health IT 9:10 Mitigating the Risks of an Audit ·· Issues to consider in order to be prepared for a potential audit ·· How to fine-tune the response to an audit request, depending on the source of the audit and its subject ·· Three potential strategies for dealing with an attestation issue that is discovered prior to an audit, potentially avoiding the need to withdraw and refund James B. Wieland, Principal, Ober | Kaler 9:50 Mock Audits: Preparing for a CMS Audit ·· Preventing recoupment by thinking like an auditor ·· Operational: finding data, organizing evidence, developing checklists ·· Quality and improvement should always be the end goal Karen A. Packard, MS, Program Manager, Meaningful Use, Information Systems, MaineHealth Gena Fouke, RHIT, BSBA, Meaningful Use Consultant, Hayes Management Consulting 10:30 Morning Break: Tea & Refreshments 11:00 OIG and Figliozzi Meaningful Use Audits ·· Understand the differences between meaningful use audits conducted by Figliozzi and the U.S. Department of Health and Human Services Office of Inspector General (OIG), including, without limitation, the extent to which incentive payments are at risk under each audit ·· Understand how to maintain appropriate documentation of meaningful use, including, without limitation, requirements for a security risk assessment under the protecting electronic health information core measure ·· Learn how to develop an effective response to meaningful use auditors ·· Understand the path from audit to appeal Daniel F. Gottlieb, Esq., Partner, McDermott Will & Emery 11:40 How to Survive Multi-Facility MU Audits ·· Identify processes and timelines preparing for a CMS audit ·· Identify key organizational strategies for audit preparation ·· Identify documents required for an audit Stephanie Battista, RN BSN, Meaningful Use Analyst and Program Coordinator, MedStar Health 12:20 Lunch Break 1:20 "Meaningful" Use of EHR Technology to Improve Patient Outcomes ·· Understand how native EMR functionality can improve communication between care teams and patients ·· Understand how an automated, real time IT intervention can help care teams recognize and intervene on critical, resulting in improved outcomes ·· Understand how to leverage existing data in electronic health records to create custom tools to support patient care Christine VanZandbergen, MPH, PA-C, Associate CIO Clinical Applications, Penn Medicine Information Services 2:00 PANEL DISCUSSION: HIT for Improved Healthcare Quality, Efficiency & Safety ·· Leveraging HIT to improve outcomes ·· Determine how “meaningful” EHR MU data is ·· Ensuring patient safety with effective use of Health IT Moderator: Thomas Novak, Director of Delivery System Reform, Office of Provider and Adoption Support, Office of the National Coordinator for Health IT Panelists: Balavignesh Thirumalainambi, MS, MBA, CPHIMS, CHTS - CP, Meaningful Use Director, New Jersey Health Information Technology Extension Center Anita Somplasky, RN CHTS-CP, CHTS-PW, Director of Quality Measure and Regional Extension Center Initiatives, Quality Insights of Pennsylvania Antonio Vega, Health Information Technology Advisor, Telligen 3:00 Close of Meaningful Use Audit and Compliance Conference from Conference Chair Thomas Novak, Director of Delivery System Reform, Office of Provider and Adoption Support, Office of the National Coordinator for Health IT facebook.com/ghpnetworkus twitter.com/ghpnetwork linkedin.com/company/ghp-network
  • 4. A Division of IQPC Healthcare Inc. Package Early Bird: Register and pay by June 5, 2015 Standard Rate: Register and pay by July 3, 2015 Late Rate: Register and pay after July 3, 2015 CONFERENCE ONLY (July 27-28) USD $1495 USD $1695 USD $1895 Yes, please register me for: Please note: • All ‘Early Bird’ discounts require payment at time of registration and before the cut-off date in order to receive any discount. • Please view our registration policy for full information about payment, cancellation, postponement,substitution and discounts. • Please note multiple discounts cannot be combined ❏ Conference Conference Venue A $99 processing charge will be assessed to all registrations not accompanied by credit card payment at the time of registration. MAKE CHECKS PAYABLE IN US DOLLARS TO: IQPC HEALTHCARE, INC Details for making payment via EFT or wire transfer: JPMorgan Chase Penton Learning Systems LLC dba ABA/Routing #: 021000021 Reference: IQPC: 25458.001 IQPC 535 5th Avenue, 8th Floor New York, NY 10017 Attn: Terence Wu Phone: 646-378-6021 Payment Policy: Payment is due in full at the time of registration and includes lunches and refreshment. Your registration will not be confirmed until payment is received and may be subject to cancellation. For IQPC’s Cancellation, Postponement and Substitution Policy, please visit www.iqpc.com/ cancellation ©2015 IQPC. All Rights Reserved. The format, design, content and arrangement of this brochure constitute a trademark of IQPC. Unauthorized reproduction will be actionable under the Lanham Act and common law principles Please note: GHP Network will never recommend, approve or appoint any third party rooming service to act on our behalf. Please be extremely wary if you are approached by any such companies. We will always endeavor to negotiate the best available rates for you so please use the Hotel´s website link provided. MAC CODE MAIL Registration Details EASY WAYS TO REGISTER: www.MeaningfulUseAuditandComplianceConference.com Call: 1-800-882-8684 EMAIL: info@GHPNetwork.com FAX: 1-646-378-60254 Sheraton Philadelphia Society Hill Hotel 1 Dock St Philadelphia, PA 19106 (215) 238-6000 For Reservations please visit: www.sheratonphiladelphiasocietyhill.com www.meaningfuluseauditandcomplianceconference.com Email: info@ghpnetwork.com Attendee Information: Name: _________________________________________________________________________________________ Company: _____________________________________________________________________________________ Phone: _______________________________ Email: ___________________________________________________ Special Dietary Needs: If you have a dietary restriction, please contact Customer Service at 1-800-882-8684 to discuss your specific needs. Payment Information: q Visa q MasterCard q American Express q Discover Credit Card Number: ____________________________________________________________________________ Expiration Date: _______/_______/_______ Security Code: ____________ Card Holder’s Name: ____________________________________________________________________________ Signature: _____________________________________________________________________________________ Billing Address on Card: __________________________________________________________________________ _______________________________________________________________________________________________ JMUJICA