Physician Assistant/Nurse Practitioner/CRNA Professional Liability Application

Transcription

1 Physician Assistant/Nurse Practitioner/CRNA Professional Liability Application (This application is used for vant Health Risk Retention Group Inc.; Triva Insurance Ltd.; and vant Health Self-Insured Trust) Name: Facility: PA or NP: Full Time: Part Time or PRN, hours per week: For questions, please contact: Angie Barnes IMPORTANT: Please complete entire application, unless specifically stated elsewhere. Signature is required on page 8 and 9: Release of Information and Claim Form. Applications will not be processed until all information is received. All questions must be answered. If not applicable, use N/A. Coverage is not in effect until application is approved and mid-level is added to the policy. The insurers of vant Health, Inc. reserve the right to deny coverage. Copies of the following are REQUIRED when your application is submitted: Current Resume or Curriculum Vitae 10-year Loss Run/ Claims History for past 10 years (If <10, back to culmination of course of study) Copy of Current Certificate of Insurance The following information will be obtained from the CVO: Employment History Educational History Applicant Demographics Current State Licensure Return Application to: Corporate Insurance Attn: Angie Barnes 2085 Frontis Plaza Blvd. Winston-Salem, NC Fax: [email protected] vant Health Medical Professional Liability Application 1 of 13

2 I. General Information (if additional space is needed, please use the supplemental form) A. APPLICANT INFORMATION Name of vant Health Corporate Entity/Partnership (where applicant will be working) Provider Last Name First Name Middle Name Degree Date of Birth Social Security # MM DD YYYY B. HOSPITALS WHERE YOU CURRENTLY HAVE PRIVILEGES 1. Hospital City State County Type of Privileges % of Practice 2 Hospital City State County Type of Privileges % of Practice 3. Hospital City State County Type of Privileges % of Practice II. Educational Background A. Have you participated in any continuing medical education within the last three years? III. Licensing Information A. Do you meet state requirements for licensure? B. Pending medical license? Pending State Temporary License# C. DEA Certificate? lf yes, DEA# If no, do you intend to apply for one? D. To which state/local medical societies or associations do you belong? vant Health Medical Professional Liability Application 2 of 13

3 IV. Rating Information A. PLEASE DESIGNATE "A (ASSIST) OR "P" (PERFORM) NEXT TO ANY APPLICABLE PROCEDURES. t Applicable ERCP rmal Obstetric Deliveries # per year Cesarean Sections # per year Abortions End Tidal CO2 Analyzer Other Medical Techniques First Trimester Acupuncture Gastrointestinal Endoscopy Pacemakers under General Anesthesia Anesthesia,Therapeutic/Local General/Spinal/Caudal Anesthesia Peritonescopy Anesthesia,General Angiography Hair Transplants Scalp Excision /Transplantation Plug /Technique/Minigraph Heart Catheterization, Left Heart Catheterization, Right (Other than CVP lines) Prenatal Practice See Patients during 1 st and 2 nd Trimester See Patients to term but do not perform delivery See Patients to term and perform delivery Pulse Oximetry Arthroscopy Swan-Ganz Catheterization Radial/Laser Keratotomy Arteriography Infertility Radiation/X-Ray Therapy Procedures/Treatments Assisting in Major Surgery Own Patients Only Laparoscopy Radiopaque Dye n-ionic Only Own Patients/Other Patients Biopsy (Endoscopic) Laser Surgery Shock Therapy Blepharopigmentation Liposuction Sigmoidoscopy Less than 60cm Greater than 60cm Blepharoplasty/Brow Lifts Lymphangiography Silicone Injections Cosmetic % of practice Reconstruction % of practice Breast Implants Lithotripsy Skin Flap/Grafts Cosmetic % of practice Cosmetic % of practice Reconstruction % of practice Reconstructive % of practice Bronchoscopy Lumbar Epidural Steroid Trigger Point Injections Paraspinal Sciatic Paravertebral Peripheral Myofascial Occipital Cryosurgery Major Gynecological Surgery Tubal Ligations (Other than external lesions) D&C Myelography Vasectomies Diagnostic Embolization Needle Biopsy Nerve Blocks vant Health Medical Professional Liability Application 3 of 13

4 IV. Rating Information B. DO YOU ASSIST WITH OR PERFORM ANY OF THE FOLLOWING: 1. Chelation therapy for other than treatment of lead poisoning: 2. Home deliveries: 3. Second trimester abortions in a non-hospital setting: 4. Bariatric surgery: 5. Sex-change operations: C. INDICATE THE PERCENTAGE OF YOUR SURGICAL PRACTICE DEVOTED TO THE FOLLOWING SURGICAL ACTIVITIES: Surgical Activities % Ophthalmology % Abdominal % Orthopedic (including back) % Cardiac % Orthopedic (not including back) % Colon/Rectal % Otolaryngology % General % Plastic (reconstruction only) % Hand % Plastic (cosmetic enhancement only) % Head and Neck % Thoracic % Neurology % Traumatic % Obstetric % Vascular % Other Describe: D. LIST DIAGNOSTIC OR SURGICAL PROCEDURES PERFORMED IN THE OFFICE BUT NOT IN THE HOSPITAL. vant Health Medical Professional Liability Application 4 of 13

5 V. Personal, Hospital, and License Information Please provide a detailed explanation for any answers on the supplemental form: 1. Do you own or operate any medical business, related to your practice or not? If yes, please describe the nature of the business enterprise and your affiliation with the entity (e.g.) owner, employee, independent contractor, etc.). Please use an additional page if necessary. Please include a copy of your certificate of insurance that provides coverage for this role. 2. Do you provide medical services to a nursing home, health care facility, or any other business enterprise providing medical services? Independent of your employment with vant Health, Inc. As an employee of vant Health, Inc. How many hours per month? Location: 3. Do you evaluate medical procedures, devices, drugs, drug regimens, therapy or clinical research or perform any procedure in your medical practice that is in an experimental stage or not FDA approved? If yes, please explain. Please use an additional page if necessary. 4. Are you now, or have you ever been treated for the use of any of the following: Alcohol Narcotics CNS stimulants or depressants If yes, did you submit your treating provider statement to the state medical board or hospital for review? 5. Are you now or have you ever been treated for any mental or emotional disorders? If yes, did you submit your treating provider statement to the state medical board or hospital for review? 6. Have you ever been convicted, found guilty, or charged with violating any federal or state law or municipal ordinance, regardless of adjudication withheld, excluding traffic offenses or minor offenses involving a fine of $ or less? If yes, please explain. Please use an additional page if necessary. 7. Has your application for medical staff privileges at a hospital or health care facility or managed care organization ever been denied or restricted? If yes, please explain. Please use an additional page if necessary. 8. Have your medical staff privileges ever been revoked, suspended or restricted? If yes, please explain. Please use an additional page if necessary. 9. Have you ever received any of the following? Any hospital disciplinary action due to professional reasons? Licensing board disciplinary or administrative proceeding due to prescribing, dispensing, or distributing pharmaceuticals? Licensing board disciplinary or administrative proceeding due to impropriety or incompetence in a medical practice? Medical society or professional organization membership denied, suspended, revoked or subject to disciplinary proceeding due to professional or ethical conduct? 10. Has your license to practice medicine or dispense narcotics ever been denied, revoked, suspended, voluntarily surrendered, or subject to probationary terms in any jurisdiction? Medical License DEA License 11. Have you ever had any professional liability insurance refused, cancelled or non-renewed? 12. Have you ever failed to participate in, or complete any risk management/quality improvement activity required by your employer? 13. Will you be carrying additional professional liability insurance with another company? If yes, state name of company, limits, and expiration date. 14. Have you ever performed any procedure for which you did not have hospital privileges for? vant Health Medical Professional Liability Application 5 of 13

6 VI. Additional Personal Information A. WILL YOU SUPERVISE ANY OF THE FOLLOWING? (IF "YES," STATE NUMBER): How Many? Nurses Nurse Anesthetists Lab and/or X-Ray Technicians Other _ Specify nature of duties: VII. Loss Information (Important-Please complete fully) Complete and attach a Claim lnformation Form for EACH such claim, potential claim, or suit. "Potential Claim or Suit" includes, without limitation, instances where you have received an oral or written communication from an individual, or his/her legal representative demanding explanations or satisfaction, or threatening legal action. It also includes requests by a patient or the patient s legal representative for copies of medical records under circumstances reasonably indicative of a possible claim or suit. A. Are you now, or have you ever been involved, directly or indirectly, in a claim, potential claim, or suit arising out of the rendering or failing to render professional services? If yes, how many? _ If yes, have these been reported to your insurer? B. Do you have knowledge of any incident, claim, potential claim, or suit in which you may become involved, including without limitation, knowledge of any alleged injury arising out of the rendering or failing to render professional services which may give rise to a claim? If yes, how many? _ If yes, have these been reported to your insurer? c. Are you aware of any occurrences having potential for a claim being made against you arising out of the rendering or failing to render professional services, with adverse results? If yes, how many? _ If yes, have these been reported to your insurer? D. If you are a member of a Partnership, Professional Corporation, or Professional Association, do you have knowledge of any claims or potential claims arising out of the rendering or failing to render professional services involving former or present partners, members of the corporation, or any former or present employee of the Corporation, Partnership, or Professional Association? If yes, how many? _ If yes, have these been reported to your insurer? E. Have you ever been involved in an obstetrical case regardless of whether case is open, closed or if a payment was made or not made? F. Have you ever been involved in a case where it has been proven that alteration of medical records has occurred, regardless of whether case is closed or if a payment was made or not? vant Health Medical Professional Liability Application 6 of 13

7 VIII. Coverage Information A. LIST ALL PREVIOUS PROFESSIONAL LIABILITY INSURERS FOR THE PAST 10 YEARS. LIST CURRENT INSURER FIRST. This section must be complete with information requested to avoid delays. 1. Name of Insurance Company: 2. Name of Insurance Company: 3. Name of Insurance Company: 4. Name of Insurance Company: 5. Name of Insurance Company: 6. Name of Insurance Company: 7. Name of Insurance Company: 8. Name of Insurance Company: 9. Name of Insurance Company: 10. Name of Insurance Company: B. Have you ever practiced without insurance or allowed a claims-made policy to lapse? C. If previous coverage was claims made: An extended reporting endorsement, (tail coverage), has been purchased. A copy of tail coverage is required. An Extended Reporting Endorsement Has t and Will t Be Purchased. I will not purchase tail coverage (reporting endorsement) from my current carrier where I am insured under a claims-made policy. I realize that my failure to purchase such coverage from my current carrier will result in an uninsured exposure for any claims which may arise in the future as result of professional services rendered while insured by my current carrier s policy. Initial Here: vant Health Medical Professional Liability Application 7 of 13

8 Warranty: Certification of Information I certify that any and all answers given above represent full and true disclosure. I understand and agree that any misrepresentation, omission, misstatement of fact in this application that is material to the risk shall be grounds for rescission of all coverage granted pursuant to this application. I understand that any and all answers to the above questions are subject to verification, and that all required documentation must be furnished, that significant discrepancies will require clarification on my part before the application can be considered. I hereby certify that following careful review of my professional activities, including patient records, I have reported to my present carrier all claims, suits, or potential claims or suits, as defined in the application, in which I am involved or in which I may become involved, arising out of events that took place during the period of my coverage with my present carrier. I understand that I will not have coverage for claims or suits, or potential claims or suits, which were or should have been reported to my present carrier. I understand that disapproval of my application in no way represents a reflection upon me personally or upon my qualifications as a practitioner of medicine. I further understand and agree that if my application is not approved, the reason(s) for its disapproval will be kept in strict confidence. I hereby agree to release from liability for slander, libel, defamation of character, or any and all other causes of action, employees of vant Health, Inc., its insurers and agents, and any of their directors, agents, designees, committees, or committee members. I AGREE TO IMMEDIATELY NOTIFY NOVANT HEALTH, INC. AND THE APPLICABLE INSURER IN WRITING IF THERE IS ANY CHANGE IN ANY ANSWER GIVEN IN MY APPLICATION, INCLUDING WITHOUT LIMITATION, ANY CHANGE IN MY PROFESSIONAL STATUS, AFFILIATION, OR WORKING ARRANGEMENT WITH ANY OTHER PHYSICIAN, FIRM OR PROFESSIONAL ASSOCIATION. I UNDERSTAND AND AGREE THAT SUCH CHANGES ARE MATERIAL TO THE RISKS COVERED BY THE INSURERS FOR WHICH I AM APPLYING. NOTICE TO ALL APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive an insurer, files a statement of claim or an application containing any false, incomplete or misleading information, is guilty of a felony in the third degree. I consent to vant Health, Inc., NHRRG, Triva Insurance Ltd, and its underwriting committee(s) accessing and reviewing any information contained in the credentialing files for any Hospitals at which I may have had or have staff privileges. I also understand that vant Health, Inc. or its insurers may wish to contact persons, hospitals, schools, employers, insurers and other entities listed in this application to verify and/or ascertain information regarding any credentials and background prior to and if issued, after the issuance of a contract. Therefore, I hereby instruct any such person, hospital, school, employer, insurer or other entity to release to vant Health, Inc. and its insurers any information regarding me, which the insurers, in good faith, believes to be applicable and pertinent to this application. A photostatic copy of this authorization shall be considered as effective and as valid as the original. PRINT OR TYPE NAME OF APPLICANT DATE EMPLOYMENT BEGINS SIGNATURE OF APPLICANT DATE OF SIGNATURE REMINDER: If you answered yes to questions in the Loss lnformation Section, you must complete a Claim Information Form for EACH claim or suit. vant Health Medical Professional Liability Application 8 of 13

9 Claim Information Form IMPORTANT: The word "claim" refers to: 1. Any suit or claim, settled or pending, regardless of the result, arising from your professional activity and brought against you or any partner, associate or employee; or 2. Circumstances which have been brought to your attention by a patient or representative of a patient, in such manner as to indicate the possibility of legal action against you, any partner, associate or employee. If there has been more than one claim, please use a separate form for each. Complete information is required. Patient Information: Name: Age: Gender: Male: Female: Date of treatment and/or surgery, which led to allegations against you: Date claim/incident notice received: Date claim reported to insurance company: Defending insurance carrier name: Allegations: What is the present condition of the patient? Did you in any way alter, embellish, delete, change and/or destroy any records, medical or otherwise, pertaining to this claim? Present status of claim (check applicable answer): Open Closed Reserve amount (if known) $ Amount paid on your behalf. $ _ Date closed I hereby authorize release to /NHRRG and its agents for information from my insurance carriers, their adjusting firms, and attorneys concerning past or present claim matters in which I am involved. X Signature of Applicant Date of Signature (A photostatic copy of this authorization shall be considered as valid as the original. Each incident/claim form must have provider's original signature.) vant Health Medical Professional Liability Application 9 of 13

10 Supplemental Form (Attach a separate sheet of paper if additional space is needed.) vant Health Medical Professional Liability Application 10 of 13

11 INSTRUCTIONS FOR PHYSICIANS/MIDLEVELS ORDERING LOSS RUNS/CLAIMS HISTORIES In order for vant Health, Inc. to provide you with medical malpractice coverage, we require that a 1 0-year loss run or claims history be provided to us in addition to your other submitted materials. We suggest that you request a copy of your loss run or claims history from either your insurance broker or insurance carrier immediately upon receipt of your application packet, as it is vital to our application process, and it sometimes takes a long time for your request to be processed by your broker or carrier. A loss run or claims history is an official document from your medical malpractice insurance carrier that indicates whether you/your practice has reported any claims to your insurance carrier and whether your carrier has reserved or paid out any money on these claims. If your residency and/or fellowship training programs falls within the past 10 years we require a loss run from the insurer as well. You can obtain these by contacting the Risk Management or Legal Dept at the institution you completed your residency and/or fellowship training program(s). Using your face sheet or certificate of insurance, locate the name of the producer in the upper left-hand corner. This will normally be your broker and often contains a telephone number or fax number, in addition to the broker s address. Telephone your broker and request a loss run or claims hist01y. The broker will need to know the insurer, which is listed in the upper right-hand corner under INSURERS AFFORDING COVERAGE; the policy number, which is located in the COVERAGES section of the certificate, usually towards the bottom third of the page, and the POLICY EFFECTIVE DATE AND POLICY EXPIRATION DATE, usually to the right of the policy number. Your broker will be able to tell you if your current carrier has 10 years' w01th of loss data, or if the broker will need prior carriers' policy numbers and policy periods from you in order to obtain the necessary reports. Occasionally, the producer is the insurance company, in which case, you may request your loss run or claims history directly from the company in the same manner described above. You may find that in order to obtain 10 years' worth of data, you may need to order these reports from different insurance carriers, as you may not have been covered under the same insurance carrier for 10 consecutive years. If you find this to be the case, simply locate your face sheet(s) or certificate of insurance(s) for the applicable year(s) and follow the steps above. You may instruct your broker or insurance company to fax or the report(s) directly to vant Health, Inc.'s. Physician Insurance Manager in the Corporate Insurance Department. Questions may be directed to: Angie Barnes Physician Insurance Manager Corporate Insurance Operations Fax: Phone: [email protected] vant Health Medical Professional Liability Application 11 of 13

12 <<Carrier>> <<Attn>> <<address/fax>> Subject: Loss Run Request Insured: Policy Number: Policy Term: To Whom It May Concern: This is an official request for the release of my current loss runs. I authorize <<CARRIER>> to release all loss run and reserve information during the time I was insured with <<CARRIER>>. Please forward this requested information to the following address/fax below: Please release this information as soon as possible. Thank you for your prompt attention to this matter. Signature Date vant Health Medical Professional Liability Application 12 of 13

13 PROVIDER OUTSIDE ACTIVITIES FORM Disclose One Activity Per Form Practitioner Name: NMG Practice: TYPE OF OUTSIDE ACTIVITY: Own Medical Business: Operate/Employee Medical Business: Independent Contractor: Medical Director: Medical Volunteer Outside U.S. (please provide details, time periods): Other (including expert witness activity): Name of Entity, Organization, Practice, etc. of Outside Activity: Complete Address: What is your Role? Is this role independent of your affiliation with vant Health? How many hours per week/month? Is there a contract or agreement for this activity? Do you receive any type of compensation including a stipend for this role or is it a volunteer role? If you are compensated in any way, does the money flow through the NMG practice or are you paid directly? Do you have separate professional liability coverage for this activity (not provided by vant Health)? Provider Signature: Date: Approved By: NMG Approved : Insurance vant Health Medical Professional Liability Application Page 13 of 13