ManagedCareMarketplace.com | Secure Payment for Listing/Storefront

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A Service of the Managed Care Information Center

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SUBMIT A LISTING -- SECURE ORDER FORM

Fill out the form below to join MCIC's Managed Care Marketplace!

A one-year Standard Listing in one category costs $750 -- $125 per month
A one-year Standard Listing in one category with one white paper posting costs $1,380 -- only $115 per month
Additional Standard Listings cost $300 each.
Storefronts cost $2,700.

SPECIAL: Sign up for a one-year Standard Listing AND two additional categories (three listings in all) and receive

10% off your order
A fourth listing for FREE

[Total comes to only $1,782 for 4 listings!]

Conditions of Your Managed Care Marketplace Listing/Storefront:
	• Standard listings are for one-year duration.
	• The shortest length of time for a Storefronts is one year.
	• Additional standard listings may be added for $300 each.
	• Companies purchasing storefronts can purchase additional listings additional categories for $100 each.
	• Every member qualifies for a 250-word description of company and products with full contact information and link to company's web site.
	• Every member will receive a FREE Sponsorship in MCIC's e-mail newsletter, "Managed Care Weekly Watch" (a $700+ value).

Please fill in the following information as you would like it to appear in your listing. After you submit this form, you will be given directions on how to submit logos, banner ads and sponsorships. [ * denotes a required field ]
	* What kind of listing would your company prefer? Special Price - Must type in keycode to honor the discount One-Year Standard Listing ($750) One Year Standard Listing with White Paper ($1,380) One Year Storefront ($2,700)
	* Which category would you like your listing/storefront to appear in?

Administrative Outsourcing
Application Service Providers
Assisted Living
Behavioral Health
Billing/Coding/Reimbursement
Business Service Bureau
Case Management/Utilization Review
Claims Processing
Complementary/Alternative Medicine
Conferences/Continuing Education
Consulting
Contract Management
Credentialing
Customer Service Outsourcing
Data Warehousing
Defined Contribution Plans
Decision Support Business Intelligence
Disease Management
E-Commerce
EDI Clearinghouse
E-Healthcare
Electronic Document Delivery
Employee Assistance
Fraud & Abuse / Compliance
Health Benefits
Health & Managed Care Data
Health Risk Assessment
HIPAA Solution Providers
HMO Management
Home Health
Hospice
Insurance
Internet/Intranet/Extranet
IT Solutions
Laboratory Services
Long-Term Care
Management Software
Marketing/Public Relations
Medical Supplies/Equipment
Network Connections
Pharmaceuticals/Pharmacy Services
Product Design Research
Physician Practice Management
Quality Assurance
Rehabilitation
Research/Publications
Risk Adjustment
Satisfaction Research
Specialized Industry Printers
Staffing Services
Telephone Services
Transportation Services
Wellness/Prevention
Workers' Compensation

If you are purchasing a Standard Listing, and would like to be listed under Additional Categories, please indicate your choices below.

2nd Category: ($300)
3rd Category: ($300)
4th Category: [FREE*]
*With the purchase of 2nd and 3rd category.
5th+ Categories: ($150 each)

If you are purchasing a Storefront, you can be listed in Additional Categories for $100 each. Please list them here:

* Company Name:

Company Address:

City:

State:

Zip:

Country:

* Company Phone:

Company Fax:

Company E-mail:

Company Web Site:

Company Contact:

Contact's Title:

Description of Company
(up to 250 words):

Would you like your listing to include your company's logo?
Yes No

NOTE: You must send us your logo. Directions on how to submit a logo will appear after you submit this form.

* How would you like to pay for your listing?
Invoice my company (Purchase Order Required -- Listing will be posted when payment is received)
Credit Card

Visa
MasterCard
American Express

Card Holder Name:

Credit Card Number:

Expiration Date (MM/YY):

If you were asked to reference a specific KEYCODE, please enter it here.

Key Code:

* Person who filled out this form:

* Title:

* Phone Number:

* E-mail:

©2003 Managed Care Marketplace.com
The Managed Care Information Center
1913 Atlantic Ave., Suite F4, Manasquan, NJ 08736
(732) 292-1100 | fax (732) 292-1111
e-mail: info@ManagedCareMarketplace.com
FEIN 22-2565612

* Company Name:
Company Address:
City:
State:
Zip:
Country:
* Company Phone:
Company Fax:
Company E-mail:
Company Web Site:
Company Contact:
Contact's Title:
Description of Company (up to 250 words):

	Would you like your listing to include your company's logo? Yes No NOTE: You must send us your logo. Directions on how to submit a logo will appear after you submit this form.
	* How would you like to pay for your listing? Invoice my company (Purchase Order Required -- Listing will be posted when payment is received) Credit Card

	Visa MasterCard American Express
	Card Holder Name: Credit Card Number: Expiration Date (MM/YY):

* Person who filled out this form:
* Title:
* Phone Number:
* E-mail: