DEPARTMENT OF HEALTH & HUMAN SERVICES |
Public Health Service |
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Indian Health Service «FacilityName» «FacilityAddress» |
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VERIFICATION OF MEDICAL MALPRACTICE
«RS_Name» «RS_Address» «RS_Address2» «RS_City», «RS_State» «RS_Zip»
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Email: |
«RS_Email»
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To Whom It May Concern:
RE: «FormalNameWithDegree»
The practitioner listed above has applied to our facility for appointment/reappointment. On «hisher» application this practitioner has indicated a professional liability policy with your company.
Before we can process this application further, we require verification of dates of medical malpractice coverage and a claims history:
Current/Previous Policy #: |
«IS_PolicyNumber» |
Inception Date: |
«IS_Issued» |
Expiration Date: |
«IS_Expired» |
Provider’s first date of coverage: |
_______________________ |
Policy Limits: |
«IS_Coverage» |
Any claims? |
*YES____ NO____ *If YES, please attach a copy/copies of claim history. |
Signature: ___________________________________________ Date: __________________
Printed Name and Title: ________________________________________________________
Please return this form or other response via secure email or fax to _________________.
Sincerely,
«UserFullName»
Medical Staff Professional
________ Indian Medical Center
Attachment: IHS Conditions of Application & Release «Image:File_REL»
According to the Paperwork
Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information
collection is [####-####]. This information collection is to be
used in verifying an applicant’s credentials to meet agency
policy and accrediting body standards. The time required to
complete this information collection is estimated to average less
than 15 minutes per response, including the time to review
instructions, search existing data resources, gather the data
needed, to review and complete the information collection. This
information collection is required to determine an applicant’s
credentials to provide healthcare (IHS IHM 3-1.4 C. (6)) and [the
nature and extent of confidentiality to be provided, if any ((the
Privacy Act, 5 U.S.C. § 552;
the Privacy
Rule promulgated under the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), 45 CFR Part 160 and Subparts A
and E of Part 164; the
Indian Health Care Improvement Act, 25 U.S.C. §
1675; and the Confidentiality of Substance Use Disorder Patient
Records regulations, 42 C.F.R. Part 2)]].
If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write
to: Indian Health Service, OMS/DRPC, 5600 Fishers Lane,
mailstop: 09E07, Rockville, MD 20857Attention Collections Clearance
Officer
Medical Staff Credentialing Office Direct: (602) 248-4190 (602) 263-1200, ext. 1918/1929 Fax: (602) 200-5383
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | {#FILE "LIADDR |
Author | CBR Associates, Inc. |
File Modified | 0000-00-00 |
File Created | 2024-07-25 |