Healthcare Medmal Renewal Form

Healthcare Medmal Renewal Form

Purpose: This form is the practitioner's application for renewal of professional liability (medical malpractice) coverage. Complete all sections fully and accurately. Material misrepresentation, omission, or concealment of facts may constitute grounds for denial of coverage or rescission of the policy. Attach supplemental pages where additional space is required.

Provider Information

Provider Name:

Practice / Employment Information

Coverage / Insurance Information

Hospital Privileges, Affiliations & Procedures

Claims / Disciplinary History

Within the last ten years, have any malpractice claims, suits, settlements, or judgments been made against you, whether or not covered by insurance? Yes No

Have you ever been subject to disciplinary action by a licensing board, hospital, or other health care entity? Yes No

Risk Management, Training & Health

Have you participated in risk management or patient safety programs in the last 24 months? Yes No

Authorization to Obtain Records & Privacy Acknowledgment

I hereby authorize any hospital, clinic, professional association, insurance company, licensing board, or counsel to provide the insurer or its representatives with information concerning my professional background, credentials, malpractice history, claims, and other relevant records. I understand this authorization will remain in effect until the earlier of the issuance/renewal decision by the insurer or the expiration date below.

Privacy Notice and HIPAA Acknowledgment: By signing below I acknowledge receipt of the insurer's privacy and data use policies as provided in connection with underwriting and claims processing and consent to use and disclosure of health information as necessary for underwriting, claims handling, quality assurance, and legal compliance.

Declarations, Certifications & Agreement

I declare that the statements in this application are complete and truthful to the best of my knowledge and belief. I understand and agree that this application, including attachments and materials provided in support, shall form the basis of the policy renewal and shall be relied upon by the insurer. I understand that coverage may be rescinded, denied, or modified if any statement or representation is found to be false or incomplete and material to underwriting the risk.

I authorize the release of information necessary to process this renewal application, including but not limited to licensing board actions, claims history, hospital privileging information, and disciplinary matters. I understand my right to receive a copy of this authorization upon request.

Signature attests that the signatory is authorized to execute this application and that any entity information provided is true and accurate. I agree to notify the insurer promptly of any material changes in risk or practice that occur prior to the effective date of renewal.

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