mediclaim.ca

Enter the data for a referring physician that is not yet included in our database and we will update our records.

Your Email Address:
*Required
Subject/Referral Physician Information:

MSP Number:
*Required - and MUST be the correct number!!
Doctor Last Name:
*Required
Doctor First Name:
*Required
Doctor Middle Name ( or initial):

College ID:
*Required * but 00000 is acceptable if unknown
Office Address:

Office City:
*Required
Office Postal Code:

Office Phone:

Office Fax:

Province:

Nature of Practice: