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Patient Communications, it’s as easy as 1, 2, 3!

Yes, I want to record confidential messages such as lab reports, referrals or
other health related information for each patient and give them access to their
information when they want!

Name of Practice: Type of Practice (describe): Number of Physicians: Contact: Practice Location: (Physical Street Address) City:     State:      Zip: Phone:   Fax: Email Address: How do you wish to be contacted? Mail Phone Email Fax (check all that apply) Have you spoken with a representative from our company?   Yes No If so, who? How did you hear about us? Web site / Search Engine Direct Mail Tradeshow Newspaper / Magazine MAG Mutual Employee Colleague Other   If other, please explain: Information collected on this page will not be divulged or distributed to any individual or organization outside of MAG Mutual Insurance Company or the MAG Mutual Group of Companies without your express permission, or as required by law.