Form 0917-0009 Malpractice Verification

DEPARTMENT OF HEALTH & HUMAN SERVICES	Public Health Service
	Indian Health Service «FacilityName» «FacilityAddress»

VERIFICATION OF MEDICAL MALPRACTICE

August 2, 2023

«RS_Name» «RS_Address» «RS_Address2» «RS_City», «RS_State» «RS_Zip»
	Email:	«RS_Email»

To Whom It May Concern:

RE: «FormalNameWithDegree» DOB: «BirthDate» SSN: «SSN»

The practitioner listed above has applied to our facility for appointment/reappointment. On «hisher» application this practitioner has indicated a professional liability policy with your company.

Before we can process this application further, we require verification of dates of medical malpractice coverage and a claims history:

Current/Previous Policy #:	«IS_PolicyNumber»
Inception Date:	«IS_Issued»
Expiration Date:	«IS_Expired»
Provider’s first date of coverage:	_______________________
Policy Limits:	«IS_Coverage»
Any claims?	*YES____ NO____ *If YES, please attach a copy/copies of claim history.

Signature: ___________________________________________ Date: __________________

Printed Name and Title: ________________________________________________________

Please return this form or other response via secure email or fax to _________________.

Sincerely,

«UserFullName»

Medical Staff Professional

________ Indian Medical Center

Attachment: Statement of Understanding and Release «Image:File_REL»

Medical Staff Credentialing Office  Direct: (602) 248-4190  (602) 263-1200, ext. 1918/1929  Fax: (602) 200-5383