Physicians Regulatory Insurance Program Application

First Name: *

Last Name: *

Agency: *

Contact: *

Address:

City: * State: *

Zip Code: *

Business Phone: * Fax: *

E-mail Address: *

I. GENERAL INFORMATION

Applicant's Name (If entity please state):

Address:

City: * State: *

Zip Code: *

Business Phone: *

Fax: *

Requested Retroactive Period: 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year *

Name of entity as it is to appear on policy documents:

Type of entity (i.e. P.A., P.C., LLP, Partnership):

Specialties of practice:

Please provide the following census information, including all practitioners whether employed or contracted:

Number of Practitioners in Group:

Number of Physicians working more than 20 hours per week:

Number of Physicians working 20 hours or less per week:

Number of Nurse Practitioners/Midwives/CRNAs:

Number of RNs, LPNs and Physician Assistants:

II. PAYOR INFORMATION

Please provide your Medicare Billing Numbers:			Please provide your Medicare Billing Numbers:
Payor	Gross Billings for the past 12 months	Collections for the past 12 months	Physicians	*
Medicare	$ *	$ *
Medicaid	$ *	$ *	Nurse Practitioners / Midwives / CRNAs	*
Medicare-HMO	$ *	$ *
Other	$ *	$ *	RNs, LPNs and Physicians Assistants	*
Total	$	$

III. BILLING PROCEDURES

Does your practice have a billing compliance program? If answering "no", please describe your billing guidelines on a separate piece of paper.	YES NO *
Does your practice have a written policy regarding collection of receivables balances?	YES NO *
If answering "yes", does the policy include write-offs of outstanding balances, co-payments and deductibles?	YES NO *
What edition of the CPT manual are you currently using for your practice?	YES NO *
Does your practice keep a separate file of outstanding/denied/questioned EOBs?	YES NO *
Are all contracts and referral relationships reviewed by outside counsel to ensure they conform with anti-kickback statutes?	YES NO *
Are billing and procedure codes monitored to alert practice management of possible upcoding, over-utilization or other billing anomalies?	YES NO *
Does your practice monitor free and / or discounted samples of medications and supplies to guard against co-mingling with purchased inventory or inappropriate billing for items dispensed?	YES NO *
Does your practice have a written policy assuring compliance with HIPAA regulations?	YES NO *
Have you or anyone within the entity ever been reviewed by the State Board of Medical Examiners?	YES NO
Have you or anyone within the entity ever lost any medical practice privileges, other than voluntary termination, with any provider?	YES NO
Have you or anyone within the entity ever been investigated or sanctioned by any local, state or federal government or agency regarding the delivery of health care services or reimbursement thereof?	YES NO

If billing is currently performed by a third party billing company, please provide the following information:

Billing Company's Name:

Address:

City: * State: *

Zip Code: *

Please describe any common ownership that exists between the Applicant's practice and the third party billing company.

Does the third party billing company have a compliance program? YES NO *

If billing is currently performed in-house, please provide the following information:

Number of individuals responsible for billing:

Number of credential billers:

IV. PHYSICIAN/PRACTITIONER WARRANTY (To be completed and signed by all applicants)

Each Physician or other practitioner to be named on the schedule of insureds must respond to the following 2 statements, sign and date below. If you cannot agree to either of the following 2 statements, please attach a detailed explanation.

Statement 1. I agree with the above physician/practitioner warranty.

Statement 2. I have no knowledge of any specific claims or facts, circumstances, situations, events or transactions that may result in a claim which may be covered by the proposed policy.

PLEASE BE SURE TO RESPOND TO BOTH STATEMENTS WHERE INDICATED AND SIGN AND DATE WHERE INDICATED, UNDATED SIGNATURES CANNOT BE ACCEPTED

	Applicant's Name (Please type or print legibly)	Signature	Date	Response to Statement 1		Response to Statement 2
1 *				agree	disagree	agree	disagree
2				agree	disagree	agree	disagree
3				agree	disagree	agree	disagree
4				agree	disagree	agree	disagree
5				agree	disagree	agree	disagree
6				agree	disagree	agree	disagree
7				agree	disagree	agree	disagree
8				agree	disagree	agree	disagree
9				agree	disagree	agree	disagree
10				agree	disagree	agree	disagree

* Required fields