AAHP-RRG Professional Liability Questionnaire (PLQ) - Self-Insurance Programs_ Self-Insurance Programs

AAHP-RRG PROFESSIONAL LIABILITY COVERAGE QUESTIONNAIRE

Requested Policy Start Date *

To allow time for underwriting and processing, the start date must be at least 30 days after the date this questionnaire is submitted to AAHP-RRG Insurance Services.

Select Your University Affiliation *

If UF Health Facility was selected above, select facility/facilities in which you are affilated.

List your University/Facility Affiliation Contact Name, Title, and Email Address or Phone # *

This individual will be contacted to confirm your affiliate status and referral for AAGH-RRG membership consideration.

GENERAL PROVIDER INFORMATION

Name *

First

Last

Preferred Email *

Email

Confirm Email

Cell Phone *

Other Phone

Personal Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Degree *

Florida Board License # (Please include the prefix. E.g., ME, OD, PA) *

Select the county where the majority of your patient care will be provided. *

List the names and address of the facilities where you will be providing clinical services. *

SPECIALTY INFORMATION

Surgery Class *

NONE: Includes incision of boils & superficial fascia, suturing of minor lacerations and removal of superficial skin lesions by other than surgical excision. MINOR: Includes operations not considered to involve a risk to life, circumcisions, & non-major OB procedures. Excludes all surgeries and procedures that meet the criteria of major surgery. MAJOR: Includes removal of tumors, open bone fractures, amputations, removal of any gland or organ, plastic surgery, tonsillectomy, adenoidectomy, caesarean section, and any operation in or upon any body cavity, including but not limited to cranium, thorax, abdomen or pelvis or any other operation that because of the condition of the patient or the length or circumstances of the operation presents a distinct hazard to life.

Medical or Surgical Specialty *

NICA: All prospective and active AAHP-RRG members who practice obstetrics or perform obstetrical services on a full or part-time basis will be required to provide proof of NICA participation with this questionnaire submission and on an annual basis thereafter. https://www.nica.com/medical-providers/

If Other selected above, please define:

Medical or Surgical Sub-Specialty *

If Other selected above, please define:

Medical Techniques or Procedures *

Exclusion 1: Does not include occasional emergency insertion of pulmonary wedge pressure recording or temporary pacemaker, urethral caths, or umbilical cord cath for diagnostic purpose or for monitoring blood gases in newborns on oxygen; Exclusion 2: Does not include fine needle aspiration and does not include liver, kidney or bone marrow biopsy; Exclusion 3: Does not include dilation with bougie or olive Exclusion; 4: Not applicable to Radiologists

If Other selected above, please define:

ADDITIONAL UNDERWRITING INFORMATION

1. Will you be providing on-site clinical services outside the state of Florida? *

YES
NO

If YES selected above, list the states where additional services will be provided, and the % of time performing out of state services (>/-=50% or <50%)

2. Will you be providing telemedicine? (Telemedicine definition: the practice of health care delivery by a practitioner who is located at a site other than the site where the recipient is located for the purposes of evaluation diagnosis and or treatment in parentheses.) *

YES
NO

If YES selected above, list the states where additional services will be provided, and the % of time performing out of state services (>/-=50% or <50%) (copy)

Bank he/she Florida

3. Has your license to practice medicine or your permit to prescribe drugs ever been denied, revoked, suspended, placed on probation, subjected to reprimand, voluntary surrendered or any other way limited, or has it been or is it currently under investigation? If YES, please attach a detailed written explanation. *

4. Have you ever been or are you currently under a consent order? If YES, attach a copy of the consent order and its termination if applicable. *

5. Have your hospital staff privileges ever been denied, suspended, revoked, placed on probation, voluntarily surrendered or in any other way restricted, or have they been or are they currently under investigation? If YES, please attach a detailed written explanation. *

6. Has any insurance company ever cancelled, declined to issue or refuse to renew your professional liability insurance, or offered such insurance only on special terms, or have you been notified of such intent? If YES, please attach a copy of the cancellation notice or letter if applicable. *

7. Have any claims been asserted or civil actions filed against you alleging errors or omissions, or against your employer or any other entity responsible for or alleged to be responsible for your patient care activities, or have you been notified that such an action will be filed? If YES, please complete a Claim Supplement form for each claim and civil action. *

8. Have any judgments been made against you, or any out-of-court settlements been made on your behalf, from an event alleging medical errors or omissions that were not addressed in #7 of? If YES, please fully complete a Claim Supplement form for each claim. *

9. Have you ever been convicted of a criminal offense or are or are you under investigation for criminal offense? If YES, please attach a detailed written explanation. *

10. Have you been treated for alcoholism or drug addiction within the last five years? If YES, please attach a detailed written explanation including dates and locations of all treatments and the names of your supervising and monitoring physicians. *

11. Have you incurred or become aware of having a condition that impairs your ability to practice your specialty? If YES, please attach a detailed written explanation. *

EVENT REPORTING REQUIREMENTS

When to Contact the AAHP-RRG:

As a covered FL AAHP provider, it is essential and expected that you notify us immediately if:  You were involved, or alleged to have been involved, in an event while delivering healthcare services that may have caused or resulted in an injury (real or perceived) to a patient;  You received a complaint, legal notice, or licensure investigation notice related to your delivery of healthcare services;  You received a subpoena for deposition or medical records.

How to Contact the AAHP-RRG:

You must notify us in writing by one of two options: 1) Complete an Event Notice and mail to the AAH-RRG by mail, or 2) Report the event online at: SIPSAAHP.org. If questions, call us at 844-693-5747 and we would be happy to assist you.

REQUIRED: Upload your CV. *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

REQUIRED: Upload your National Practitioner Data Bank Report. *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

REQUIRED: Upload a 10-year Claim History report from your insurance carrier(s). *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Upload Explanations and/or Claim Supplement Forms for YES responses in the ADDITIONAL UNDERWRITING INFORMATION section.

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

If applicable, upload NICA Participant Certificate for current calendar year.

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

PROVIDER REPRESENTATIONS: By selecting YES below, I hereby declare that the statements and responses I have provided in this questionnaire are, to the best of my knowledge and recollection, complete and correct and that I have not deliberately suppressed or misstated any material facts. If any material change occurs during the term of my policy, I agree to immediately notify the AAHP-RRG in writing at the following email address: InsuranceServices@SIPSAAHP.org *

YES

AUTHORIZATION FOR RELEASE OF INFORMATION: By selecting YES below, the undersigned hereby authorizes his/her present and prior professional liability insurance carriers and any and all attorneys who have represented the undersigned in connection with any claim of professional liability to release to the AAHP-RRG, upon its request, information regarding closed, pending, or anticipated claims and any underwriting or other information which in the judgment of any such carrier, attorney or the AAHP-RRG may have a bearing upon his/her professional liability risk factors. The undersigned also authorizes all medical associations, medical societies, and managed care organizations in which he/she is or has been a member, all hospitals in which he/she now holds or has held staff privileges, the state board of medical examiners for the state in which he/she has practiced, the state department of public health for the state in which he/she has practiced or resided, and any and all physicians having information regarding the undersigned, to release to the AAHP-RRG, upon its request, any information any such person or entity may have which, in the judgment of any such person or entity, has a bearing upon his/her professional liability risk factors. *

YES

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Signature *

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