CONTROLLED RISK INSURANCE COMPANY OF VERMONT, INC. (A RISK RETENTION GROUP) CONTROLLED RISK INSURANCE COMPANY, LTD. Physician Application Please type or print responses in ink, and answer all questions in full. If a question does not apply to you, state none or NA (Not Applicable). If you require more room for your answers, please attach additional pages. Questions in boxes should be completed by your Credentialing Department. Application Type New Applicant Sponsor/Employer Change Applicant Returning to CRICO Employment Status Change Specialty Change: attach a Delineation of Privileges (DOP) document A new application is not required for name changes. To submit a name change, send a request accompanied by a marriage certificate or court order to underwritingapps@rmf.harvard.edu. GENERAL INFORMATION 1 Name Last Degree First Middle Suffix Position Title, e.g., Chief of Service, Director, Chief Medical Resident, etc. Other legal names you have or have had, e.g., pre-marriage. 2 Age & Gender Date of Birth: Month Day Year Male Female 3 Social Security # INSTITUTION AFFILIATION 4 Sponsoring Institution Institution sponsoring your medical professional liability insurance Department Chief of Service 5 Primary Employer The entity named on your IRS W2 form. Sponsoring Institution (identified in Q4) Other entity (e.g., foundation, professional corporation, physician practice group, etc.): CRICO-affiliated: sponsored by institution named in Q4 n-crico entity or individual: 6 Employment Status Staff Physician Fellow Resident 7 Coverage Effective date of coverage: MM/DD/YY To be completed by the credentialing department. revised 9.2016 page 1 of 7
CREDENTIALING Attach additional pages if necessary. 8 Medical Education Medical School /Country Graduation Date (year) Include all states in License Number 9 License(s) which you are licensed. Renewal Date (MM/DD/YY) License Number Renewal Date (MM/DD/YY) License Number Renewal Date (MM/DD/YY) License Number Renewal Date (MM/DD/YY) 10 Board Certification(s) Name of Board Name of Board Name of Board 11 Teaching Status a) If you check any item except Not applicable, you must complete section b. b) Harvard Academic Appointment Full Professor Associate Professor Assistant Professor Instructor/Lecturer t applicable If you have a Harvard Academic Appointment, what student type applies? (Check all that apply.) Attending Physicians Nurses Dental Students Residents/Fellows Medical Students CONTACTS Apartment/unit number Your primary 12 Home Address residence at the time of your employment with your CRICO sponsor. 13 Contact Information Where would you like to receive correspondence from CRICO? (check one) Please provide both At practice site (see Q14): a b c d At my home your work and home information. We will honor your preference Primary Phone (###-###-####) for correspondence, @ but require both for Primary Work Email Home Email our records. @ revised 9.2016 page 2 of 7
LOCATIONS 14 Practice Sites a) List all organizations at which you practice clinically or at which you have privileges, including international sites. Is this your primary practice site? Are you providing: Direct Patient Care Indirect Patient Care Telemedicine Is this site covered by the Federal Tort Claims Act (FTCA)? b) Is this your primary practice site? Are you providing: Direct Patient Care Indirect Patient Care Is this site covered by the Federal Tort Claims Act (FTCA)? Telemedicine c) Is this your primary practice site? Are you providing: Direct Patient Care Indirect Patient Care Is this site covered by the Federal Tort Claims Act (FTCA)? Telemedicine d) Is this your primary practice site? Are you providing: Direct Patient Care Indirect Patient Care Is this site covered by the Federal Tort Claims Act (FTCA)? Telemedicine 15 Telemedicine If you checked telemedicine in any item in Q14, please indicate the type of service provided: Check all that apply. Physician to Physician Physician to Patient General Consulting (e.g., radiology reads, second opinions, etc.) revised 9.2016 page 3 of 7
SPECIALTY CLASS 16 Hospitalist 17 Specialty Please select all specialties that apply. *Applicants must submit a Delineation of Privileges document. **Applicants must submit a Delineation of Privileges document AND complete the radiology supplement form (page 7). Are you a hospitalist? Allergy Anesthesiology* Cardiac Surgery Cardiology with major invasive/cath/icu* Cardiology* Dentistry Dermatology* Diabetes* Emergency Medicine Endocrinology* Family Medicine* Family Medicine with limited OB* Gastroenterology* General Surgery Genetics Geriatrics* Gynecology* Gynecology Surgery* Hand Surgery* Head and Neck Surgery* Hematology* Immunology Infectious Diseases* Intensive Care Medicine (not cardiac ICU) Internal Medicine* Neonatology Nephrology* Neurology* Neurosurgery Nuclear Medicine Nutrition, clinical OB/Gyn Surgery* Obstetric Surgery* Occupational Medicine Oncology* Ophthalmology* Ophthalmology Surgery* Oral Surgery Orthopedic Surgery Otorhinolaryngology* Otorhinolaryngology with plastic surgery* Pain Management* Palliative Care with focus on pain management* Palliative Care with some or no focus on pain management* Pathology* Pediatrics* Pharmacology, clinical Physiatry/Physical Medicine & Rehab Physician, NOC, with major invasive procedures* Plastic Surgery, NOC* Podiatrist Psychiatry, including child* Psychiatry with ECT* Pulmonary Diseases* Radiation Oncology* Radiology, cardiac caths** Radiology, interventional diagnostic** Radiology, diagnostic** Retired or Teaching Physician* Reproductive Endocrinology and Infertility, including IVF* Rheumatology Sleep Medicine* Sports Medicine* Thoracic Surgery Urology Urgent Care* Vascular Surgery Other (specify):* 18 Procedures Indicate all the procedures you perform. When possible, estimate the number of procedures performed annually. Note: Radiology procedures are listed separately on the radiology supplement form (page 7). Angiography Arteriography Arthroscopy Aspiration, biopsy, or drainage using ultrasound or other guidance Biopsy of nerve, muscles, significant internal organs Biopsy, other (specify): Bronchoscopy Catheter placement, central artery, Swan-Ganz, intercostal, umbilical, implantable ports Catheter placement, permanent Catheterization, cardiac Circumcision Closed reductions of fractures and/or dislocations Colonoscopy Dilation (specify): Endoscopy ERCP Esophagoscopy First assist in OB procedures Laparoscopy Lumbar puncture Open reductions Pacemakers, permanent Pacemakers, temporary Plastic surgery Plastic surgery, cosmetic Sigmoidoscopy Spine procedures (specify): Surgical assist TEE TTE Thoracentesis or paracentesis Thoracentesis or paracentesis, at bedside revised 9.2016 page 4 of 7
SPECIALTY CLASS (continued) 19 Description of Practice Please provide a brief summary of your day-to-day clinical practice. See the example provided. Example Description: I am a board-certified OB/Gyn physician who has been actively practicing since 2005. In my current role, I will be practicing as a Gyn physician only, seeing patients in an outpatient setting 4 days a week with 1 day a week in the OR. PROFESSIONAL FUNCTIONS Staff physicians only. 20 Professional Activities Indicate your average level of activity. In a typical week, I work hours in total. My time is divided among these activities (these hours should add up to the total above): hours providing direct patient care hours providing supervised (precepted) patient care hours in administrative activities hours conducting research hours teaching hours in another professional activity (specify): COVERAGE HISTORY Staff physicians only. 21 Previous Insurers Insurer/location where you practiced (facility & state) Attach additional pages if necessary. If you have a gap in coverage greater than three months, please provide an explanation. Start date (MM/DD/YY) Start date (MM/DD/YY) End date (MM/DD/YY) Insurer/location where you practiced (facility & state) End date (MM/DD/YY) Any claims? Any claims? Insurer/location where you practiced (facility & state) Start date (MM/DD/YY) End date (MM/DD/YY) Any claims? 22 Ten-year Claims History Attach all insurance company(ies) report(s) of claims history for the last ten years in practice. The ten-year claims history should include the policy number(s), coverage dates, and for each claim the claim number, description of loss, final disposition, and settlement amount. Claims history reports should be no older than six months. The report(s) must be submitted whether or not the physician has ever been named in a claim or suit. LEGAL BACKGROUND 23 Hospital Discipline Including restriction of privileges I have had no hospital disciplinary actions or restrictions of privileges in the past ten years. Name of Hospital and or and Country Date of Action Result of Action 24 Board Disciplines Or other governmental body I have had no state board disciplinary actions in the past ten years. Board Name and or and Country Date of Action Result of Action revised 9.2016 page 5 of 7
LEGAL BACKGROUND (continued) 25 Criminal Convictions I have not been convicted of any crimes by any governmental agency in the past ten years. Crime of which you were convicted and or and Country where charged Date of Conviction Sentence 26 Criminal Indictments I have not been under indictment for any criminal or civil offense in the past ten years. Accusation and or and Country where indicted Date of Indictment Result of Indictment 27 Review To be completed by the sponsoring institution. If any disciplinary action, convictions, or indictments are reported above, has the legal background been reviewed by the Chief of Staff and/or Legal Counsel? PHYSICIAN SIGNATURE 28 Release of Information and Attestation Note: Your signature is required following this Release of Information statement. I hereby authorize Controlled Risk Insurance Company of Vermont, Inc. and Controlled Risk Insurance Company, Ltd. (CRICO) and Risk Management Foundation of the Harvard Medical Institutions, Inc. (RMF) to obtain full information from any insurance company or from any person with respect to me or my medical practice, including, but not limited to, any claim or suit or incident pertaining to professional acts or omissions asserted against me and/or my partnership or professional corporation. I understand all information furnished to CRICO, whether orally, in writing, or electronically, shall be held in confidence and used solely for the purpose of providing medical professional liability insurance, including underwriting risk and reporting as required by law. I expressly release and discharge from liability any insurance company or persons providing such information. I further authorize that a photocopy of this release be accepted with the same authority as the original. The information I have provided is complete and accurate. Personal Signature of Applicant Date Signed CREDENTIALING DEPARTMENT To be completed by the sponsoring institution. 29 Authorization It is the responsibility of the sponsoring institution to review and meet CRICO eligibility requirements as well as state requirements prior to adding any new physicians. Name of authorized institution representative (print) Title Authorized signature Date Signed Please email this application to underwritingapps@rmf.harvard.edu or fax it to 617.450.8297. Please do not send applications to individual staff members. The email address (or fax number) above is required to ensure that applications are processed appropriately. revised 9.2016 page 6 of 7
Radiology Supplement If you selected Radiology on Q15 of the crico Physician Application, you must complete this supplementary form to determine your classification for the CRICO insurance program. S1 Diagnostic Radiology Non-interventional, No Surgery S2 Cardiovascular and Interventional Radiology Check all that apply: General diagnostic procedures including ultrasound and CT imaging Nuclear Medicine general diagnostic Ultrasound examinations general diagnostic (no amniocentesis, no aspiration biopsy and drainage procedures using ultrasound guidance) Please estimate the number of each procedure performed each month. # Code Description RA02 Angiography diagnostic (includes arteriography & venography) RA03 Angiography therapeutic-embolic procedures RA04 Angiography therapeutic-transluminal angioplasties RA05 Arthrography RA06 Aspiration biopsy & drainage procedures using ultrasound guidance RA07 Bronchoscopy RA08 Cervical puncture for myelography RA09 Cysternal puncture for myelography RA10 ERCP (endoscopic retrograde cholangio-pancreaticogram) RA11 Extremity arteriography RA12 Hysterosalpingography RA13 Injection for hysterosalpingography RA14 Laryngography RA15 Lumbar puncture for myelography RA16 Lymphangiography RA17 Mammography RA18 Myelography RA19 Percutaneous aspiration & biopsy of deep structures RA20 Percutaneous biliary drainage RA21 Percutaneous carotid arteriography RA22 Percutaneous trans-femoral arteriography, arch and/or cerebral RA23 Percutaneous trans-hepatic removal of gallstones RA24 Percutaneous urinary drainage/antegrade pyelography RA25 Puncture for antegrade pyelography RA26 Renal cyst puncture RA27 Sialography RA28 Trans-duodenal pancreatography RA29 Trans-hepatic cholangiography RA30 Trans-hepatic puncture RA31 Trans-lumbar aortography RA32 Venography extremity RA33 Venography other RA34 Cardiac catheterization SIGNATURE S3 Physician Signature The information I have provided is complete and accurate. Signature Date Print Name revised 9.2016 page 7 of 7