Print out a copy of this form. Fill in the needed information and indicate the program(s)
and date(s) you wish to attend. Please print clearly! Mail the form with a check in the
correct amount payable to Med•Lantic Management Services, Inc. Note: Credit card
payments are not accepted for mail-in registrations. Use our online registration if you
wish to pay by credit card. |
| Program
Cost $50 per
person |
|
|
|
|
| Program |
Specify
Code |
Specify
Date |
Cost |
|
Medical Matters |
|
|
|
|
Communicating Unanticipated Outcomes
to Patients |
|
|
|
Total Cost |
|
| Name |
| Address |
| City |
State |
Zip |
| Office Phone # |
|
Office
Fax # |
| Medical License # |
| Specialty |
If you do not have an individual policy
with
ProAd, please indicate your group policy name: |
| Notes |
|
Enclose the completed form and a check with full
payment in an envelope and mail to:
Med•Lantic Management
Services, Inc.
P.O. Box 64100
Baltimore, MD 21298-9134 |
Risk Management
