Mail-In Registration for Physician Programs

Register By Mail

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.

Cost for First Program Selected - $50 per person

Cost for Each Additional Program - $25 per person

Program	Specify Code	Specify Date	Cost
EMR, EHR and PHR: Risk Reduction Strategies in the Physician Office Practice
Medical Matters: Six Rules for Physicians
Total Cost

Name

Address

City

State

Zip

Office Phone #

Office Fax #

License

Specialty

Notes

FOR OFFICE USE ONLY

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