1. Healthcare

GLOBAL HEALTH CONSULTANTS, LLC
Linda K. Dixon CPC, CPC-I, CCP, ASC-EM, ACS OBY/GYN
234 Hobart St. Meriden, CT 06450
203-440-9975 203-440-9962(back office)
fax: 203-440-9288
PLEASE FAX ALL 12 PAGES OF THIS FORM AND A PHOTO COPY OF A
GOVERNMENT ISSUED PICTURE ID TO: 203-440-9288 OR SEND IT BY MAIL
GHC APPLICATION FOR CLASSES AND EXAMS Membership, Exam, Tuition, Books and Fees
CPC & CPCA
ICD-10
ONCOLOGY
CMRS
CPC-H
ER
CMPA (Auditing and Compliance)
AUDITING-CEMC
ANESTHESIA
SPECIALITY ________________
CIC
__________
PLEASE PRINT
Name ______________________________________________________________________________
Home Address: ______________________________________________________________________
City/state/zip _______________________________________________________________________
Home/day/evening phone _______________________Work phone____________________________
Cell phone _______________________ Emergency Phone Number____________________________
Employer Name ______________________________________________________________________
Email Address _______________________________________________________________________
High school attended ________________________________________Year graduated________________
Education or training _____________ GED __________
Do you work in the field? Yes No.
Other certificates______________
Do you run your own business? Yes No
AAPC member number:______________________ or Social Security number:__________________
ALL APPLICANTS MUST SUBMIT A COPY OF A VALID GOVERNMENT ISSUED PICTURE ID
PRINT Student Name ____________________________________
Date______________________
Signed by student: ________________________________________
©Global Health Consultants, LLC. January 2015 PAGE 1 of 12
GHC APPLICATION FOR CLASSES AND EXAMS: Membership, Exam, Tuition, Books and Fees (continued )
1. AAPC Membership: Payable to AAPC,
(required, CMRS requires AMBA membership)
I am enrolling as an AAPC member so I can sit for my CPC-A exam.
____Regular member ($120) ____Student member ($70)* Submit a copy of AAPC membership card to GHC
Healthcare Business Monthly magazine and complimentary newsletters are included with an annual membership.
See http://www.aapc.com/resources/publications/index.aspx for more information.
The AAPC Code of Ethics can be found at http://www.aapc.com/AboutUs/code-of-ethics.aspx All students must
abide by the AAPC Code of Ethics.
2. EXAM REGISTRATION Students who wish to pursue the CPC or CPC-A Exam or any specialty MUST register
and pay for exam at least seven weeks prior to exam date via the AAPC Website. AAPC will deny access to the exam
if you do not pay fees in advance. Ask Linda for Exam Index # and student discount code.
CPC /CPC-A EXAM Payable to AAPC: I am registering for the _____CPC/CPC-A EXAM ($260)
I understand the cost of the test is $330 (see aapc.com for more information) or $260 if taught by Linda Dixon, an
AAPC licensed instructor. I agree to attend the classes for CPT-ICD-9, ICD-10 and HCPCS coding because I want
to pass the CPC-A to CPC exam. I understand that review sessions will also follow training classes to prep me for
the 5 hour 40 minute exam. I understand that I will have homework and that these exercises will help prepare me for
the exam.
ICD 10 EXAM
Payable to AAPC: I am registering for the _____ ICD-10 EXAM ($ 60)
SPECIALITYTY EXAM Payable to AAPC: I am registering for the _______EXAM
($ see AAPC.com)
I understand that the cost of the test and regulations applying to the test vary by AAPC specialty and that I must pay
for and register for the exam at AAPC.com at least seven weeks prior to exam date via the AAPC website.
3. TUTITION: ENROLL IN CLASSES
$250.OO DEPOSIT TO HOLD PLACE IN CLASS, Payable prior to class NON-REFUNDABLE required for ALL classes.
CLASS TUITION:
CPC & CPC-A $3,200
ICD-10 $475.OO
CMRS $450.OO
CPC-H $475.00
CMPA
CEMC AUDITING $475.00
$600.00
CIC $600.00
exam)
ONCOLOGY $475.00
ER $475.00
ANESTHESIA $475.00
RE-REVIEW FOR CPC EXAM $495.00 (non GHC students, after failing
RE-REVIEW FOR CPC EXAM AFTER 2ND EXAM FAILURE (GHC students only) $150.00
Global Health Consultants, LLC. January
2015 PAGE 2 of 12
BOOKS, FEES, OTHER TRAINING MATERIALS
$250.OO DEPOSIT TO HOLD PLACE IN CLASS, Payable prior to class NON-REFUNDABLE (we hold the seat for you,
this does not allow another student to take your seat)
REQUIRED BOOKS: ICD-10 $_________ ICD-9 $________ STUDY GUIDE $_________ HCPC $_______
WORKBOOK $__________
CPC $_________ OTHER _________ $_________
*Students may purchase their books on their own.
OTHER _________ $_________
Students who wish to pursue the CPC or CPC-A Exam or any specialty MUST register and pay for exam seven weeks
prior to exam date via the AAPC Website. AAPC will deny access to the exam if you do not pay fees in advance.
4. STUDENT AGREEMENT
I have read the entire GHC APPLICATION FOR CLASSES AND EXAMS and understand that I am responsible for cost of
AAPC membership, cost per EXAM, cost per class (tuition), cost for books and other training materials, and
understand that all three are separate charges for my training. CPC EXAM: I understand I can take the CPC Exam
two) times if needed for the initial cost of $330 or $260. I have registered I have been informed that the training in
medical terminology and anatomy will aid me and prep me for the exam, but is no guarantee that I will pass. The
passing of the CPC Exam and all other AAPC exams will depend on my learning, application of what I have learned,
practice and dedication towards the readiness for taking test.
I understand that a nonrefundable deposit of $250 is required to hold my seat in class.
I have read the AAPC guidelines for other AAPC exams for which I am registered.
I will notify Linda K. Dixon at (203)-440-9975 or (203)-440-9962 if I cannot attend a class so that she can work with
me to make up the lesson. I will follow all class rules (see page 6 of this document)
TOTAL COSTS FOR TUITION, BOOKS, FEES and OTHER TRAINING MATERIALS:
$________
You cannot take the exam unless you are paid in full for all GHC classes.
PRINT Student Name ____________________________________
Date_____________________________
Signed by student: ________________________________________
©Global Health Consultants, LLC. January 2015 PAGE 3 of 12
GHC APPLICATION FOR CLASSES AND EXAMS: Membership, Exam, Tuition, Books and Fees (continued)
Payment Plan: Must sign PROMISORY PAYMENT PLAN AGREEMENT beginning on the next
page
TOTAL due $_________ _________________________________ (student signature)
$_____ Weekly Payments EVERY week
_____________________________ (student signature)
$ _____ Monthly Payments By the 10th of the month _________________________________ (student signature)
Pay in Full:
TOTAL due $________
____________________________________ (student signature)
Method of payment:
_______ Credit Card or ATM (Visa, Mastercard, Discover, AMEX) _____ Cash ______ Money order or bank check
_____ Check MAKE CHECK PAYABLE TO: Linda Dixon or Global Health Consultants, LLC
Card Number________________________________ Expiration Date________________________
Name as it appears on the card________________________________________________________
Card Security code____________ (on the back for most credit cards, front for American Express) Billing
Zip code for billing address of card: ________________________________________________________
Absences that are not called in in advance are subject to a “NO SHOW” fee of $50.00
_______ I agree that I will make all payments in a timely fashion before my exam is taken. Tuition
must be paid every week or if monthly, before the 10th of the month.
PRINT Student Name ____________________________________
Date_____________________________
Signed by student: _________________________________ Signed by GHC______________________________
PROJECT XTERN Information (Externships help students get jobs )
1. Global Health Consultants is approved by the AACP (American Academy of
Professional Coders) as a Project Xtern site for students at no cost.
2. Do you need to complete an externship after completing your education program?
__yes __no 3. Are you interested in participating in the AAPC Project Xtern program?
__yes __no 4. If you are interested you must supply a resume to GHC (Global Health
Consultants).
For detailed information see: http://www.aapc.com/medical-coding-jobs/project-xtern/index.aspx
©Global Health Consultants, LLC. January 2015 PAGE 4 of 12
GLOBAL HEALTH CONSULTANTS, LLC
LINDA DIXON, CCP, CPC-I, ACS-E&M/AUDITOR
234 Hobart Street, Meriden, CT 06450
PROMISSORY PAYMENT PLAN AGREEMENT
I, ____________________________________(print name) a student taking CPC or
specialty classes _______________________________ from Global Health Consultants,
LLC/Linda Dixon, CCP, CPC-I, fully understand and agree to a payment plan. I have signed the
promissory note for the class/books/exam/membership, etc. depending what was needed for
classes.
I understand I will select the best suited payment plan for my financial situation by initialing
the type of payment plan and the amount to be paid as listed below:
_____________ WEEKLY payments of $___________ must be made every
week until paid in full, by the 5th class.
_____________ MONTHLY payments of $___________ must be made
between the 1st to the 10th day of each month until
paid in full.
_____________ LUMP sum payments must be made every month until
paid in full.
I agree to pay in full (all) of my costs before I take the CPC exam or the specialty exam,
unless otherwise discussed and other terms are agreed to with Linda Dixon.
I understand my seat placement is guaranteed and held for me when I start the classes. I
am still responsible for payments until I have paid the full amount. The $250.00 deposit to hold
my seat will be applied to my bill as a payment. I understand Linda Dixon will work with me in
the payment plan. The payment plan may only be changed if agreed to with Linda Dixon. I am
responsible for full payment after I have started the class with no refunds if I quit coming to class.
I understand I must call if I cannot make it to class.
Agree to the above & signed by Student________________________ date_______
Agreement with GHC/Linda Dixon ___________________________ date______________
©Global Health Consultants, LLC. January 2015 PAGE 5 of 12
DUE ON A SPECIFIC DATE PROMISSORY NOTE
Total Amount of Note: $_________________
Date: ___________________
RE: STUDENT NAME: __________________________________________________________
Home Address:_____________________________________ State_______ ZIP_________
CPC PREP CLASSES: Tuition $3,200.00
Specialty Classes: Tuition & full cost $
For the VALUE of weekly [14 to 20 weeks] CPC (Certified Professional Coders) Prep Exam Classes with the CPC
Exam
administered
on
site,
the
undersigned,
Student
name
_____________________________________________ (known as the “borrower”), at the above home address,
promises to pay to the order of Linda Dixon or Global Health Consultant, LLC (the “Lender”), located at 234
Hobart Street, First Floor, Meriden, CT 06450, or such other place as the Lender may designate in writing) the
sum of $3,200.00 (tuition for classes) plus any additional borrowed costs ______________ as requested from
student
(i.e.,
books,
exam,
membership
etc.)
__________________________________________________________________________________________
Which will total $________________________ for total amount borrowed by this student.

No interest will be charged on the tuition of $ 3,200.00 (plus any other costs –books, exam, membership,
etc. / borrowed) from the start of classes [start date________________] on the unpaid principal; at an
annual rate of 0% if the sum is paid in full by or before the scheduled date of the CPC exam for the full
costs. There are no refunds after second class, the seat is held.

Specialty classes the Tuition + other costs = $ ______________ Name of Specialty________________

If the students does not pay the full amount of the exam, they agree to postpone the certificate exam
until set payment is made in full. Starting the date of the exam, interest may be added to the total cost
due and will be calculated monthly on that full amount still outstanding.
Acceptable Payment arrangements promised by the student:
□_________ (student to initial) Accepted payment plan for LUMP SUMS: are 1/3 of the total due must be
paid within the first 4 weeks of class. The second 1/3 of the total due must be paid between the 5 th and 8th
week. The final payment must be made before the exam, between the 8 th and 12th week. All payments must
be before the last date of class and before the CPC is taken.
□_________ (student to initial) WEEKLY PAYMENT of $___________________ have been discussed and
accepted by the Lender with the full sum of the weekly payments totaling $3,200.00 (plus any other costs) and
will be paid in full before the CPC exam.
©Global Health Consultants, LLC. January 2015 PAGE 6 of 12
□_________
(student to initial) The Borrower understands that the AAPC (American Academy of
Professional Coders) will not allow the Borrower to take the CPC exam or Specialty exam until they have paid
the PMCC Lender in full the amount before the exam is taken. The Borrower holds harmless the AAPC and
Lender from all liabilities due to their nonpayment.
□_________ (student to initial)
Promissory note does not apply pending the promise that the student
is a WIA student, TAA, or the employer and this outside party has promised to pay in full for the amount
borrowed.
If the WIA, TAA or employer payments are not made, the student will be fully responsible for the payments.
Interest will be calculated on the entire amount monthly until the payment is paid in full.
The unpaid principal and accrued interest shall be payable in full on the date before the CPC exam or the
student will not take the AAPC exam. If the unpaid principal is paid after the “due date” accrue interest at
monthly rate at stated by the statues of the State of CT or a flat fee of $180.00 per month will be added to the
balance until the full amount is paid.
All payments on this note shall be paid in the legal currency of the United States and will be applied first to the
accrued interest and the remainder of payments to the principal. This note may be prepaid (in whole or in
part) prior to the Due Date with no prepayment penalty. There is no interest for payments made during the
course classes.
If any of the following events of default occur, this Note and any other obligations of the Borrower to the
Lender, shall become due immediately, without demand or notice:
(1) the failure of the Borrower to pay the principal and any accrued interest in full on or before the Due Date;
(2) the death of the Borrower or Lender [the Borrower’s estate shall honor the full amount to pay] ;
(3) the filing of bankruptcy proceeding involved the Borrower as a debtor [the borrower agrees to have
full amount paid back and excluded from any bankruptcy;
(4) the application for the appointment of a receiver for the Borrower;
(5) the making of a general assignment for the benefit of the Borrower creditors;
(6) divorce proceeding, the Borrower agrees to pay without regards to such proceedings;
(7) employer agrees to pay for their employee –the Borrower-and then refuses, the Borrower agrees to
pay the amount in full;
(8) the insolvency of the Borrower; or the misrepresentation by the Borrower to the Lender for the
purpose of obtaining or extending credit [i.e., Department of Labor is supposed to pay per the
Borrower and they have no intention to pay; or WIA is supposed to pay per the Borrower and the
Borrower has not been approved as a student and WIA has no intention to pay; WC or an Attorney
promising to pay per the Borrower and the Attorney/WC has no intention to pay.
If any payment obligation under this Note is not paid when due, the Borrower shall be obligated to pay all costs
of collections, small claims court, collection agencies, all Attorney fees (including all filing fees, verification of
address of the Borrower, serving fees, administration fees) whether or not a lawsuit is commenced as part of
the collection process. The Borrower waives presentment for payment, protest, and notice of protest and
nonpayment of this Note.
©Global Health Consultants, LLC. January 2015 PAGE 7 of 12
It is further recognized that the Lender allows the student to pay during the course weekly, monthly, or by lump
sum with no interest rate and works with the student with the sum to be paid at the end of the classes.
No renewal or extension of this Note, delay in enforcing any right of the Lender under this Note, or assignment
by the Lender of this Note shall affect the liability or obligations of the Borrower. All rights of the Lender under
this Note are cumulative and maybe exercised concurrently or consecutively at the Lender’s option.
This note shall be construed in accordance with the laws of the State of Connecticut. If anyone or more of the
provisions of this Note are determined to be unenforceable in whole or in part for any reason, the remaining
provisions shall remain fully operative.
The Lender may ask the student not to return to class if payments of some arrangements are not made and the
CPC exam may be withheld until satisfactory payment arrangements are made and kept. The
Borrower/student signed and agreed to payment for prep classes for taking the CPC exam (plus any other costs)
the payment is for classes, holding the seat for the student and is not based on the passing of the CPC exam by
individual students. Furthermore, the student realizes that once the classes are started and two classes have
been attended, the student/Borrower is responsible for the full amount borrowed since the seat was held for
that student with the intension of them taking the full class.
Signed on this day ______________ of month________________, year 20______, at 234 Hobart Street,
Meriden, CT 06450 [or other location of ___________________________________________], I the Borrower
have read and agree to the above promise to pay course classes, books, AAPC Exam, AAPC Membership, and
any other related cost to this course, including any collection or attorney costs due to the fact that I have not
honored this agreement.
Borrower: Print Student Name:__________________________________________________________
Print home address:__________________________________________________________
Print City: ____________________________, State:_________________ Zip ____________
Home phone: _______________________________ Cell phone:_______________________
Signature of Student (Borrower) ____________________________________________________________
Signature Lender/Member of GHC ____________________________________ Linda Dixon, CCP, CPC-I
Date:__________________
Lender: Global Health Consultants, LLC
(The Gatekeeper to Medical Coding)
234 Hobart Street
Meriden, CT 06450
Witness to signature:__________________________________________
date:___________________
Print Name of Witness:______________________________________©Global Health Consultants, LLC.
January 2015 PAGE 8 of 12
Rlease of Information
Family educational Right and Privacy Act
Name of Student ______________________________________________________________________
Print as appears on or will appear on license or certificate
Student AAPC Member #: ____________________________
Date of Birth
_______________________________
Course Title: ________________________________________
Date of Completion ___________________________
I understand and herby authorize GHC/Linda Dixon CPC-I to release the following information:
Full name and Address
Hours of Completion
Course Title
School Name
Completion Date of Course
Email Address
Phone Number(s)
Date of birth
TO: _______ American Academy of Professional Coders (AAPC)
_______ American Medical Billing Association
_______ WIA Connecticut Workforce Investment Act Region:______
I understand further that (1) I have the right to not consent to the release of my educational records (above). (2)
I have the right to receive a copy of such request. (3) This consent shall remain in effect until revoked by me, in
writing, and delivered to Linda Dixon, but that any such revocation shall not affect disclosures made by The
gatekeeper of Medical Coding, LLC prior to the receipt of any such written revocation.
Further, I will place my required payment in a sealed envelope which I give permission to be mailed to the
organizations I checked above. In addition, I will give a copy of my registration form with any charge card
information obliterated to my course instructor to keep until such a time as my application has been successfully
posted by the organization.
I understand that if I choose not to consent to the release of my educational records listed above that my
ability to become or remain licensed or certified may be forfeited. I give permission to have my teacher get my
results from AAPC or talk to AAPC on my behalf.
PRINT Student Name ____________________________________
Date_____________________________
Signed by student: __________________________________________
©Global Health Consultants, LLC. January 2015 PAGE 9 of12
CONFIDENTIALITY CONTRACT/HIPPA AGREEMENT
Global Health Consultants, LLC directs all students and externs to contact the owner/member Linda Dixon, in person,
phone or writing about any complaints, concerns, problems or inquiries that they may have. All inquiries and/or
complaints will be handled individually, addressed, investigated and solutions or remedies discussed with the student
to help in the resolution of their concerns. The Incident/Absent/Complaint form needs to be filled out and presented
to Global Health Consultants, LLC. (form attached to this application)
If as student does not feel that they can approach Linda Dixon, they must then approach an assigned person from
Global Health Consultants, LLC by phone, in person or by letter before contacting any agencies.
Under no circumstances are any items of information regarding the operation of Global Health Consultants, LLC to be
recited, reiterated or contextually repeated outside of this office. Any person known to do so will be subject to
reprimand and removal from the school without any consideration for tuition monies paid for any period of time not
yet expended, or portion of instruction not yet received.
At no time is any material in the forms of: Instruction booklets, sheets, or any type of information related to the
instruction provided at Global Health Consultants, LLC to be taken out of the office without the prior permission of
Linda Dixon of Global Health Consultants, LLC. All property of Global Health Consultants including but not limited to
computers, tablets, books, printers, copiers are not be removed or used for personal use without written permission
from Linda Dixon.
No operational or personal documentation or verbal communication is at any time for any reason to be delivered
outside of Global Health Consultants, LLC. This included but is not limited to any and all files relating to physicians,
their practices, patients and insurance providers, business matters, personal matters, financial matters and student
matters. The established business name or any of its existence cannot be used for personal gain.
No student shall at any time use remote devices to access any software or systems belonging to Global Health
Consultants, LLC or client thereof.
Pursuant to Connecticut Education Code Section 48900-48927 “A student shall not be suspended from school or
recommended for expulsion, unless the superintendent (owner) of the school… in which the pupil is enrolled
determines that the pupil has committed an act as defined pursuant to any of the subdivisions (a) to (r) inclusive…
(a)(1) Caused, attempted to cause or threatened to cause physical injury to another person… (2) Willfully used force or
violence upon the person of another…(b)Possessed, sold, or otherwise furnished a firearm…(c) Unlawful possessed,
used, sold or otherwise furnished , or been under the influence of a controlled substance…(d)Unlawfully offered,
arranged, or negotiated to sell a controlled substance….(e)Committed or attempted to commit robbery or extortion.
(f) Caused or attempted to cause damage to school property or private property. (g)Stole or attempted to steal school
property or private property. (h) Possessed or used tobacco…property at 234 Hobart St., Meriden, CT is smoke
free}…(i)Committed an obscene act or engaged in habitual profanity or vulgarity. (j) Unlawfully possessed or
unlawfully offered, arranged or negotiated to sell drug paraphernalia…(k) Disrupted school activities or otherwise
defied valid authority or teachers, administrators…(l)Knowingly received stolen school property or private
property…(m) possessed an imitation firearm…(n)committed or attempted to commit sexual assault…(o)Harassed,
threatened or intimated a pupil...(r) Engaged in the act of bullying.
Yes, I have read, understand and agree to the above CONFIDENTIALITY CONTRACT/HIPPA AGREEMENT.
PRINT Student Name ____________________________________
Signed by student: _______________________________________
Date_____________________________
©Global Health Consultants, LLC. January 20152013 PAGE 10 of 12
GLOBAL HEALTH CONSULTANTS, LLC
234 Hobart Street
Meriden, CT 06450
INCIDENT/ ABSENT/COMPLAINT
Name:_______________________________________________________________________________
Date:____________________________________
Phone Number:_____________________________
PLEASE DESCRIBE ABSENCE ON DATE___________________________
INCIDENT: _________________________________ Date: _______________________________
Complaint or Problem:
_____________________________________________________________________________________
RESOLUTION:_______________________________________________________________________________________
Student Signature:___________________________________
Date:_______________________
GHC signature:______________________________________
Date:_______________________
©Global Health Consultants, LLC. January 2015 PAGE 11 of 12
GLOBAL HEALTH CONSULTANTS, LLC
APPLICATION FOR CLASSES AND EXAMS (continued)
Gatekeeper to Medical Coding
Classroom Rules
•
100% of my students survive the classes and are alive! Everyone must be on time when class starts and
must bring their books and papers to class. Do not shut your books or pack up before the end of class or
I will make you sit longer.
If you cannot attend class or will be late, the absences or tardiness must be agreed upon, I need a call
before class
•
Dress is informal but you must wear clothes.
•
No inappropriate language. No cell phones, tablets or other electronics on during class. Please
respect me and I will respect you. You may call me Linda.
•
You may eat (snacks and sandwiches) and drink (drinks must have lids) during class as long as you
clean up any mess. I can talk forever on coding so if it is break time please feel free to let me know
•
If you have problems come to me and let’s talk about it. I never leave anyone behind which means if
you’re not understanding the information then others are not understanding the information either and it
needs to be reviewed.
•
Homework needs to be done and if for some reason it is not please let me know ahead of time because if
you don’t you will be answering all of the questions.
•
There are plenty of billing and coding jobs available.
PRINT Student Name
______________________________
Signed by student: ______________________________________
Date__________________
©Global Health Consultants, LLC. January 2015 PAGE 12 of 12