PCF06

Revised: 01/2026

LOUISIANA PATIENT’S COMPENSATION FUND SELF INSURED
HEALTHCARE PROFESSIONAL APPLICATION

Required field notice: Fields marked "Required" must be completed.

Dates of Enrollment Applying for:

Professional Degree

am licensed to provide professional medical services as a

License Number

Date of Birth

Do you work less than 20 hours per week? No Yes

If so, complete PCF12

If advanced practice nurse, name of supervising MD:

I further certify that the appropriate security (proof of financial responsibility) is in place and current at the following institution:

	in the name of

Please check any that apply to your practice:

Botox

Facial Chemical Peels

Facial Fillers

Laser Hair Removal

Spa Services

Tatoo Removal

Employees as Additional Insureds:

Please see below inclusions/exclusions; complete the proper form and include proof of underlying coverage.

INCLUSIONS: Employed allied healthcare providers.

EXCLUSIONS: This does not include those who require a PCF surcharge, such as, NP•s, PA•s, CNS•, CRNA•s, etc.

PCF RESERVES THE RIGHT TO DENY COVERAGE FOR THE FOLLOWING:

Injury arising out of a criminal act, including but not limited to sexual abuse or molestation, fraud committed by the insured or any person for whom the insured is legally responsible, and battery.
Third (3rd) party claims filed by an injured party that was not a patient of the health care provider.
Services or treatment rendered as a licensed provider in states other than Louisiana, even if the underlying insurer provides coverage for same.

NOTE

Failure to comply with cost and reserve reporting requirements set forth in LAC 37:III, §§1101-1105 could result in termination of PCF coverage.

My self insured coverage is through:

Office Name, Address, Parish and Phone Number

Office Name and Address Line 1 (no P.O. Box)

Office Address Line 2

Office City, State Zip Code

Parish

Office Phone Number

Home Address and Phone Number

Home Address Line 1

Home Address Line 2

Home City, State Zip Code

Home Phone Number

Professional Degree

Professional Degree From

State/Country

Degree

Year

Internships and Residencies (dates, services & locations)

Current Specialty

Sub Specialty

Board Certified

Local Professional Society

Staff Privileges at

Name of Previous Liability Carrier

I am not employed by any physicians group, firm, hospital or corporation except as follows: (if no exception, so state)

Do you or your medical partnership or corporation with which you are professionally involved employ any of the following: Licensed Physician Assistants, Licensed Nurse Practitioners, CRNAs, Nurse Midwives, and/or Surgical Assistants or Pharmacists? If yes, and you wish to provide coverage through your self insurance, please list their names and include the appropriate surcharge for each.

List Names of Any Partners (if applicable)

Are you a stockholder in a professional medical corporation? No Yes

If yes, you must complete the corporation application (PCF9) from our website and return it.

Name of Corporation/Partnership/LLC/LLP/AMPC

Do you practice medicine outside of Louisiana? If yes, complete form PCF11. No Yes

Are you employed or contracted by a facility as a Medical Director? No Yes

If yes, who is your coverage through?

Please indicate percentage of time devoted to the following medical and/or surgical activities (total should equal 100%):

Addictionology

Gynecology-Surgery

Orthopedic Surgery

Administrative Medicine

Hand Surgery

Otorhinolaryngology

Aesthestic Medicine

Hematology

Otorhinolaryngology/Plastic

Allergy

Hospitalist

Otorhinolaryngology/Surgery

Anesthesiology

Infectious Diseases

Pain Management

Bariatric Medicine

Intensive Care Medicine

Pathology

Bariatric Surgery

Internal Medicine

Pediatrics

Cardiac Surgery

Laborist

Pharmacology-Clinical

Cardiovascular Disease

Neonatology

Physiatry-Phys. Med

Cardiovascular Surgery

Nephrology

Psychiatry

Colon & Rectal Surgery

Nephrology Interventional

Psycholanalysis

Dermatology

Neurology

Plastic Surgery

Emergency Medicine

Neurohospitalist

Pulmonary Diseases

Endocrinology

Neuro-radiology

Radiology-Diagnostic

Family Practice

Neurosurgery

Radiology-Therapeutic

Family Practice-Incl. OB

Nuclear Medicine

Rheumatology

Forensic Medicine

Nutrition

Sleep Medicine

Gastroenterology

Obstetrics

Thoracic Surgery

General Practice

Obstetrics/Gynecology

Trauma Surgery

General Practice-Surgery

Occupational Medicine

Urgent Care Medicine

General Preventative Medicine

Oncology-Medical

Urological Surgery

General Surgery

Oncology-Surgery

Urology/Gynecology

Geriatrics

Ophthalmology

Vascular Surgery

Geriatrics/Institutional

Ophthalmology-Surgery

Wound Care

Gynecology

Orthopedic-Office Only

Total Percentage

Please indicate which of the following medical/surgical procedures you engage in:

Do you perform x-ray or other radiation therapy? No Yes

If so, please list x-ray or Radium Technicians employed by you:

Please mail or fax to:

LOUISIANA PATIENT'S COMPENSATION FUND
P.O. BOX 3718
BATON ROUGE, LA 70821

FAX: (225) 342-5593

Signature of Insured -- NOT VALID WITHOUT SIGNATURE

Date

A PRINTED, SIGNED COPY OF THIS FORM MUST BE MAILED/FAXED TO PCF.

PCF coverage is subject to all agreements, conditions and exclusions of the underlying policy unless such agreements, conditions and exclusions are expressly prohibited by law.

Additional forms may be found on the LAPCF website: www.lapcf.info

Any questions regarding this form may be emailed to: pcf-surcharge@la.gov