TO APPLY FOR COVERAGE FOR MED SPAS, ANTI-AGING CLINICS AND ALTERNATIVE MEDICAL PRACTICES, YOU MUST FILL OUT THE FOLLOWING APPLICATION:
Complete Medical Spa Application - covers spa and physician performing direct patient care.
FAX YOUR COMPLETED, SIGNED AND DATED APPLICATION, ALONG WITH ADDITIONAL MATERIALS REQUIRED TO 704-927-5981 OR EMAIL TO COMPLETEDAPP@PROFESSIONALLIABILITYSOLUTIONS.NET.
TO APPLY FOR COVERAGE FOR AN INDIVIDUAL PHYSICIAN
You must fill out the following applications:
Individual Physician Application
Supplemental Claims - must be completed if you have any history of claims. Each claim needs its own form.
In addition to above completed, signed and dated applications, please also submit:
- Copy of your CV or resume
- Details of any previous claims, suits or licensing issues (see Supplemental Claims form above)
TO APPLY FOR COVERAGE FOR A HEALTHCARE FACILITY (i.e. MRI Centers, Surgery Centers, Laboratories, etc.)
You must fill out the following application:
Clinics (Entity) Application - covers the facility itself
In addition to above completed, signed and dated application, please also submit:
- A detailed description of operations
TO APPLY FOR COVERAGE FOR A CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA)
You must fill out the following applications:
CRNA Application - covers the Nurse Anesthetist for procedures performed
Supplemental Claims - must be completed if you have any history of claims. Each claim needs its own form.
In addition to above completed, signed and dated applications, please also submit:
- Copy of your CV or resume
- Details of any previous claims, suits or licensing issues (see Supplemental Claims form above)
FAX YOUR COMPLETED, SIGNED AND DATED APPLICATIONS, ALONG WITH ADDITIONAL MATERIALS REQUIRED TO 704-927-5981 OR EMAIL TO COMPLETEDAPP@PROFESSIONALLIABILITYSOLUTIONS.NET.
