Professional Liability Application

Thank you for your interest in the the

Volunteer and Retired Providers (VRP) Program!

The following electronic application (press "Next" below) is for VRP malpractice insurance.

If you believe that you have already applied for VRP malpractice insurance, or if you have any questions, please contact Kris Ives at:

vrp@wahealthcareaccessalliance.org

267-713-9422

APPLICANT DEMOGRAPHICS

First Name

Last Name

Professional Designation(s)

Street Address

State

City

ZIP Code

County

Preferred Phone

Home Phone

Mobile Phone

Work Phone

Preferred Email

Personal Email

Alternate Email

Work Email

Year of Birth (i.e. 1972)

Professional License Number(s), beginning with two-character license designator, followed by eight-digit license number (eg., RN00000000)

State in which license was issued

Are you board certified?

YesNo

Board Certification Date Issued (Month/Year)

Board Certification Specialty

(Fill out the section below only if you are an out of state provider.) 1. I have filled out and submitted the volunteer attestation on the Department of Health's website. (For link to the attestation, click here.)

YesNo

2. I attest that I hold a License in another US jurisdiction in a profession substantially equivalent to a profession regulated by a disciplining authority listed in RCW 18.130.040. The license must be a current, active license. I further attest that I am not presently subject to any disciplinary action or investigation for criminal or professional misconduct in any jurisdiction. (For a link to RCW 18.130.040, please click here.)

YesNo

3. I understand that I may not exceed 30 days of volunteer practice in any calendar year. A separate attestation is required for each calendar year in which I intend to volunteer.

YesNo

4. I understand that I must submit an attestation on the Department of Health's website at least 10 working days before the volunteer practice begins.

YesNo

5. I certify that I have read and understand the scope of practice for my profession in my US jurisdiction of license as well as the scope of practice in Washington State. I agree that I will not exceed the scope of practice and will meet all supervision requirements for Washington State or my US jurisdiction, whichever is more restrictive.

YesNo

Provider Status

VOLUNTEERING INFORMATION

When do you begin volunteering?

Please let us know an approximate start date for your volunteer work in order to assign a date for your malpractice insurance.

Volunteering Starting Date

Where will you be volunteering?

The VRP Program covers providers who are volunteering at program-approved sites across Washington. Please "check" all sites where you will be volunteering.

You can hold down the keys "CONTROL+F" on a PC or "COMMAND+F" on a Mac to find your site in the below list.

If you cannot find your volunteer site in the list below, please select "other" at the bottom and type where you'll be volunteering.

Location

Volunteer Sites (must be a VR approved clinic site):

Specialty that you will practice

VRP AUTHORIZATION

Will you receive any compensation for your volunteer services?

YesNo

Are you a student?

YesNo

Are you in your third year of residency? (If you are a resident, you must be in your third year and volunteer work is limited to occasional events versus a recurring shift.)

YesNo

If you are a student, can you please include your study area and confirm this volunteer work is not for credits (as that does disqualify you from VRP coverage since often covered by the Preceptor).

I understand that in participating in the VRP Program, I will be required to complete a short annual survey used to track the value of this publicly-funded program. By checking this box, I acknowledge that I understand the VRP survey requirement.

True

Scope of Care & Authorization

Scope of Care:
The VRP Program only covers non-invasive care. Please acknowledge that you understand the scope of care covered through the VRP Program.

I understand that I will only perform non-invasive care as defined below:

Non-invasive care includes the administration of injections, suturing of minor lacerations, and the incision of boils and superficial abscesses. Obstetric care and procedures coded as surgery are not covered under noninvasive medical care. Non-invasive dental care includes diagnosis, oral hygiene, restoration, and extraction. Orthodontia and surgical treatments are not covered by VRP malpractice insurance.

By checking this box, I certify that I understand the scope of care covered through the VRP Program.

True

Authorization:

I acknowledge that as a condition precedent to acceptance of this application and any future renewal thereof, an inquiry and investigation of my professional background, qualifications and competence, including such other underwriting or claim matters as are deemed relevant, may be conducted by Physicians Insurance or its duly authorized representatives. I expressly consent to any such inquiry and investigation and hereby authorize the release and exchange of information pertaining to such inquiry and investigation between any professional organizations in which I am or have been a member, their insurance consultants or agents, any hospitals at which I hold or have ever held staff privileges or have had an application for staff privileges denied, any state licensing agency, any of my attending or treating physicians, the Washington Physicians Health Program, any prior insurance carriers, prior employers or professional associates and Physicians Insurance or its duly authorized representatives. I hereby release and discharge the providers of information, Physicians Insurance, its duly authorized representatives and the members or consultants of any established peer review committees from any and all legal liabilities which might otherwise be incurred as a result of any communications, reports, disclosures and recommendations made or any acts performed, in good faith, in connection with any inquiry or investigation initiated by Physicians Insurance or its duly authorized representatives. I agree to notify Physicians Insurance immediately, in writing, if there are any changes from which I have described in this application, including changes in my practice, in my partners or associates, medical license, professional office premises, practice locations, medical procedures or administrative responsibilities and hospital privileges. I understand that Physicians Insurance does not cover any liability of another person or organization with whom I assume an oral or written contract or agreement. Washington State law requires us to inform you of the following: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.