HIPAA Privacy Compliance Resource Order Form

                       You can complete your order by phone at (800) 894-1243 or fax the completed form below to

                       Gilliland & Markette, LLP at (317) 704-2410.  Questions before ordering?  Call (800) 894-1243.

Name: __________________________________________________________________________________

Title: ________________________________________ Are you the Privacy/Compliance Officer?   Yes     No

Agency Name: ___________________________________________________________________________ 

ANCOR Member:  Yes   (ANCOR Member #: _________)     No    Member number will be verified prior to ordering.

Street Address: __________________________________________________________________________

City: ______________________________________   State:_______   ZIP Code: ______________________

Phone: ____________________  Fax: ______________________  E-mail: ___________________________

                                                                                                                                       Qty.                                  

   HIPAA Privacy Compliance Resource Manual for ANCOR Private Providers        ___    @ $495.00   $_______

   HIPAA Security Compliance Manual for ANCOR Private Providers                   ___    @ $495.00   $_______

   HIPAA Privacy Compliance Resource Manual for Group Health Plans               ___    @ $495.00   $_______  

   HIPAA Business Associate Template                                                          ___    @ $49.50   $_______                     

   HIPAA Breach Notification Rule Update—ANCOR Member                                __    @ $44.55    $_______

   HIPAA Breach Notification Rule Update —ANCOR Non-Member  Price                ___    @ $49.50     $_______

                                                                                       Less 20% if 2 or More Manuals        $_______

                                                                                                                        Subtotal   $_______      

                                                                                    Shipping* (calculated by shipper):      $_______

                                                                                                                        TOTAL:     $_______

      *Total will be calculated by Gilliland and Markette based on shipping.  There is no shipping charge for the Breach Notification Rule Update. For total price prior to ordering, please call.                                                                                                                                                                                                                                     

Credit Card Number: _________________________________   Exp. Date: _________    Security Code_______

Name on Card:  ________________________________  Signature of Cardholder: ________________________

Billing Address:  _____________________________________________________________________________

Shipping Address:          Same as Billing Address                 Same as Street Address Above

                                   New Shipping Address: _______________________________________________________

Fax Credit Card Orders to: (317) 704-2410

 Make Checks Payable to: Gilliland & Markette, LLP, 3905 Vincennes Road, Suite 204, Indianapolis, IN  46268

 Ordering Questions: (800) 894-1243