Medical Insurance Exchange of California - Professional Liability Insurance

MEDICAL RECORDS DOCUMENTATION ORDER FORM
Name:
Address:
City, State, Zip

Please print this page, supply your name and mailing address, enclose a check for $40 made payable to Medical Underwriters of California and mail to MIEC Loss Prevention 6250 Claremont Avenue Oakland, CA 94618

6250 Claremont Avenue, Oakland, CA 94618 800.227.4527 Fax 510.654.4634