Cna Form G 119639 A is a new form that was recently released by the Centers for Medicare and Medicaid Services (CMS). This form is designed to help nursing facilities improve their quality of care. The form will be used to collect data on pressure ulcers and falls, which are two of the most common types of complications in nursing homes. This information will help CMS track and monitor the quality of care at nursing homes nationwide. Nursing homes that do not submit data on these two items may face penalties from CMS.
| Question | Answer |
|---|---|
| Form Name | Cna Form G 119639 A |
| Form Length | 8 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 2 min |
| Other names | HealtPhysAppPhy siciansNBIdaho_ CNA cna healthpro medical practitioners renewal application form |
CNA HEALTHPRO
MEDICAL PRACTITIONERS APPLICATION
I PERSONAL/PROFESSIONAL DATA
Name (last, first, middle, designator)
Clinic name/Employer
Date of birth (MM/DD/YY)
Primary practice address |
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Zip Code |
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Residence address |
City |
State |
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Zip Code |
County |
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Telephone - office |
Fax number |
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Telephone – residence |
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Number of years at current office location |
If less than three years, list previous locations and dates |
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Tax I.D. number |
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Social Security number |
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Additional practice locations |
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PLEASE ATTACH A COPY OF YOUR CURRENT POLICY DECLARATIONS PAGE AND BUSINESS LETTERHEAD. Desired policy dates
Effective date: |
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Prior Acts date: |
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Desired coverages/limits |
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Professional liability |
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each claim/ $ |
aggregate |
Personal umbrella (not available in all states) |
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COMPANY/AGENCY USE ONLY
Territory
Dec ISO
PLD code
Policy number
Group
Producer number
Step
Rate ISO
Rate class
Account number
Producer’s name
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II MEDICAL TRAINING AND HISTORY
Please answer all questions completely. If a question does not apply to you, mark “N/A” or “0.”
Do not leave any questions unanswered. If space is inadequate, use the Comments section or attach a separate sheet.
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Medical specialty: |
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Percentage of practice: |
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Percentage of practice: |
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2. |
Medical education |
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A. Medical school: Institution |
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To |
Completed? |
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No |
Yes |
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B. Internship: Institution |
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From |
To |
Completed? |
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No |
Yes |
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C. Residency: Institution |
Specialty |
State |
From |
To |
Completed? |
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No |
Yes |
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D. Residency: Institution |
Specialty |
State |
From |
To |
Completed? |
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No |
Yes |
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E. Fellowship: Institution |
Specialty |
State |
From |
To |
Completed? |
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No
Yes
3.If you are a graduate of a foreign medical school:
are you certified by the Education Council for Foreign Medical Graduates?
have you passed the FLEX? No Yes
4.Number of hours continuing education completed within the past two years:
5.Date and location you began practicing:
Date
6.Medical license information
No Yes
hrs.
City,State
State
License number
Expiration date
Status
7. |
Narcotics/DEA license number: |
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Status: |
8.Board certification information
Name of board:
Name of board:
Name of board:
Certified
Certified
Certified
Qualified
Qualified
Qualified
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II MEDICAL TRAINING AND HISTORY (continued)
9.List the corresponding medical associations/societies of which you are a member:
A.County:
B.State:
C.National:
10.Has your board certification or membership in any medical association/society ever been voluntarily or involuntarily suspended, denied, revoked or restricted in any state?
No
Yes — Explain:
11.Has your medical or narcotics license ever been voluntarily or involuntarily suspended, denied, revoked or restricted in any location?
No
Yes — Explain:
12.Have you ever been diagnosed with, or treated for, alcoholism, drug addiction, or mental or physical impairment?
No
Yes — Explain:
13.Have any fee, professional relations or other complaints been registered against you with any medical association, state licensing authority or hospital?
No
Yes — Explain:
14.Have you ever been charged with any criminal activity?
No
Yes — Explain:
15.Has any claim or suit for alleged sexual misconduct ever been brought against you?
No
Yes — Explain:
16.Have Medicare or Medicaid authorities ever brought charges against you?
No
Yes — Explain:
III INSURANCE HISTORY
1. |
Carrier information |
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Current carrier |
First prior carrier |
Second prior carrier |
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Insurance company |
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Coverage form |
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Occurrence |
Occurrence |
Occurrence |
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Policy period |
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Limit of liability |
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per claim/aggregate |
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Deductible |
Deductible |
Deductible |
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Deductible or S.I.R. and amount |
S.I.R. |
S.I.R. |
S.I.R. |
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$ |
$ |
$ |
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Prior Acts date |
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III INSURANCE HISTORY (continued)
2.Has your insurance for medical malpractice ever been canceled, suspended,
No
Yes Explain:
3.Have you ever had professional liability insurance provided by CNA?
4.If you are currently insured by a
A.Are you obtaining Extended Reporting (“tail”) coverage from your current insurance company?
B.Is Prior Acts coverage being requested? If Yes, show Prior Acts effective date:
and attach a copy of your most recent policy declarations page.
C.Has your practice changed significantly in the last five years?
No Yes Explain:
No
No No
Yes
Yes Yes
Note: To prevent possible gaps in your
IV CURRENT MEDICAL PRACTICE
1.Do you practice medicine on a
2. |
Percentage of your practice outside of your primary state? |
% |
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List States: |
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3. |
Percentage of your practice devoted to practicing as a locum tenens: |
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4. |
Type of practice: (Check all that apply.) |
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Solo Practitioner |
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Partnership |
Name: |
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Group |
Name: |
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Employee |
Of: |
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Space sharing |
With: |
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Independent contractor |
For: |
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No
Yes
5.Do you supervise residents?
No
Yes |
If yes, how many? |
6.Do you have any medically related duties that are insured by another company or for which you do not desire CNA Coverage?
No
Yes Explain:
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Percentage of |
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7. |
Check all with which you are associated: |
Name |
Practice |
Relationship |
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Solo Practitioner |
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Governmental body |
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Military service |
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Educational institution |
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Professional sports team |
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Clinic with inpatient facilities |
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Urgent care center |
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Commercial laboratory |
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Administrative position |
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Surgicenter |
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Office with surgical suite |
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Nursing home or long term care facility |
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IV CURRENT MEDICAL PRACTICE (continued)
8.Are you under contract (other than PPO, HMO, IPA or anything listed in Question 7) in any capacity involving the practice of medicine?
No
Yes Explain:
9. |
Do you have hospital privileges? |
No* |
Yes |
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Hospital Name |
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City, County, State |
Type of privilege |
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Full |
Courtesy |
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Restricted |
Other* |
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Full |
Courtesy |
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Restricted |
Other* |
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Full |
Courtesy |
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Restricted |
Other* |
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*If No, Restricted or Other, please explain on your letterhead.
10.Have your hospital privileges ever been suspended, denied, revoked, restricted or otherwise sanctioned?
No Yes Explain:
11.Do you work in the emergency department other than to fulfill requirements for you hospital privileges?
No Yes List number of hours per week:
12.Do you perform or assist in any surgical procedure in a
No Yes Complete the following:
A.Do you follow ASA standards for preoperative monitoring?
No
Yes
B. |
Number of procedures annually: |
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Description: |
C.Anesthesia administered by:
13.Do you perform surgery (see categories - these lists may not be all inclusive)?
No Surgery — perform neither surgery nor obstetrical procedures. Incising of boils and superficial fascia, suturing or minor lacerations, removal of superficial skin lesions by other than surgical excision and assisting in surgery are not considered surgery.
No
Yes
Minor Surgery — applies to all general practitioners or specialists, except those performing major surgery or anesthesiology, who may perform any of the following medical techniques or procedures: colonoscopy, endoscopic retrograde cholangiopancreatography (ERCP), pneumatic or mechanical esophageal dilation (not with bougie or olive), tonsillectomies, and adenoidectomies.
No
Yes
Please list types of procedures routinely performed:
Major Surgery — includes operations in or upon any body cavity including, but not limited to, the carnium, throax, abdomen, pelvis or any other operation which because of the condition of the patient or length of the circumstances of the operation presents a distance hazard to life. It also includes: removal of tumors, open bone fractures, amputations, termination of pregnancy, the removal of any gland or organ (excluding tonsillectomies and adenoidectomies), plastic surgery and any operation done using general anesthesia.
No Yes
number per year
Please list types of procedures routinely performed:
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IV CURRENT MEDICAL PRACTICE (continued)
14.Please answer the following. If you answer yes to any question with asterisks(**), please explain fully on your letterhead.
Average number of patients seen per week:
Do you perform the following procedures?
A.Elective cosmetic surgery
B.Itinerant surgery
C.Vaginal deliveries
D.Cesarean sections
E.Deliveries outside the hospital
F.Abortions
G.Neonatology
H.Professional sports medicine
I.Angiography/arteriography/ cardiac catheterization
No
No
No
No
No
No
No
No
No
Yes — percentage of practice: |
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Yes **
Yes — number per year:
Yes — number per year:
Yes **
Yes |
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percentage of practice: |
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Yes |
— |
percentage of practice: |
% |
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Yes ** |
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Yes |
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J.Experimental procedures
K.Weight control surgery/drugs
No
No
Yes **
Yes ** percentage of practice: |
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L.If you are a primary care physician, do you automatically receive the results of tests and consultation/exam reports ordered by the physician/surgeon to whom your patient was referred?
No
Yes — How quickly do receive them?
V CLAIMS HISTORY
Has any claim or suit for alleged malpractice ever been brought against you or are you aware of any circumstances that might lead to such a claim or suit?
No
Yes — Complete the following. If you need more space, use the comments section or attach an additional sheet.
Patient’s name
Insurance carrier
Allegations
Claim closed.
Claim open.
Date of occurrence
Location of occurrence
Amount paid on your behalf
$
Amount reserved on your behalf
$
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V CLAIMS HISTORY (continued)
Patient’s name
Insurance carrier
Allegations
Claim closed.
Claim open.
Patient’s name
Insurance carrier
Allegations
Claim closed.
Claim open.
Patient’s name
Insurance carrier
Allegations
Claim closed.
Claim open.
Date of occurrence
Location of occurrence
Amount paid on your behalf
$
Amount reserved on your behalf
$
Date of occurrence
Location of occurrence
Amount paid on your behalf
$
Amount reserved on your behalf
$
Date of occurrence
Location of occurrence
Amount paid on your behalf
$
Amount reserved on your behalf
$
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COMMENTS SECTION
Question number Comments
AUTHORIZATION
I have answered the questions in the Application to the best of my ability and declare that, to the best of my knowledge, the statements set forth herein are true and correct. My signing of the Application does not bind the Insurance Company to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a policy be issued.
For FL, KY, MN, NJ, NY, OH and PA residents only: Any person who knowingly and with intent to defraud any Insurance Company or other person who files an Application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. For NY residents only: And shall also be subject to a civil penalty not to exceed five thousand ($5,000) dollars and the stated value of the claim for each such violation.
Signature in Full |
Date |
Name - Please print
ALL QUESTIONS MUST BE ANSWERED AND THE APPLICATION MUST BE SIGNED AND DATED.
This program is underwritten by and Application is made to one of the CNA Insurance Companies. CNA is a registered service mark of the CNA Financial Corporation.
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