PCF Procedure Questionnaire for practitioners with
“minor” surgery or “major” surgery designation

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

Complete Name

Professional Specialty

Date of Birth

License #

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

Amputation Specify:

Explanation of Laser Procedures:

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

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