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Excellence in Physician
Liability Protection
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Refer your colleagues to MPT
Please FAX this form to (213) 473-8781.
Or Call Liza Campos at (800) 252-7706.
Or email ecampos@cap-mpt.com.
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MPT Member Name: _________________________
You may use my name as a reference: YES: NO: |
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Physician(s) you are referring
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Name: _________________________ Specialty: _________________________
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Address: ___________________________________
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City: _____________________ State: _____________________ Zip: __________
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Office Phone: __________________ Office Fax: __________________
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Physician is: Solo With a Group Name of Group: _________________________
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I have spoken to this physician about CAP-MPT: YES NO
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Name: _________________________ Specialty: _________________________
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Address: ___________________________________
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City: _____________________ State: _____________________ Zip: __________
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Office Phone: __________________ Office Fax: __________________
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Physician is: Solo With a Group Name of Group: _________________________
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I have spoken to this physician about CAP-MPT: YES NO
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Name: _________________________ Specialty: _________________________
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Address: ___________________________________
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City: _____________________ State: _____________________ Zip: __________
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Office Phone: __________________ Office Fax: __________________
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Physician is: Solo With a Group Name of Group: _________________________
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I have spoken to this physician about CAP-MPT: YES NO
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Name: _________________________ Specialty: _________________________
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Address: ___________________________________
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City: _____________________ State: _____________________ Zip: __________
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Office Phone: __________________ Office Fax: __________________
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Physician is: Solo With a Group Name of Group: _________________________
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I have spoken to this physician about CAP-MPT: YES NO
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