0917-0009 Malpractice Verification

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

VERIFICATION OF MEDICAL MALPRACTICE

July 25, 2024

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

To Whom It May Concern:

RE: «FormalNameWithDegree»

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: IHS Conditions of Application & Release «Image:File_REL»

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is [####-####]. This information collection is to be used in verifying an applicant’s credentials to meet agency policy and accrediting body standards. The time required to complete this information collection is estimated to average less than 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is required to determine an applicant’s credentials to provide healthcare (IHS IHM 3-1.4 C. (6)) and [the nature and extent of confidentiality to be provided, if any ((the Privacy Act, 5 U.S.C. § 552; the Privacy Rule promulgated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Part 160 and Subparts A and E of Part 164; the Indian Health Care Improvement Act, 25 U.S.C. § 1675; and the Confidentiality of Substance Use Disorder Patient Records regulations, 42 C.F.R. Part 2)]]. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Indian Health Service, OMS/DRPC, 5600 Fishers Lane, mailstop: 09E07, Rockville, MD 20857Attention Collections Clearance Officer

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