PCF QUESTIONNAIRE FOR PART-TIME PROVIDERS
AND/OR ADMINISTRATIVE MEDICINE PROVIDERS

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

Provider Name:

Professional Specialty:

Coverage Period: to
Part Time Effective Date:

Underlying Insurer: OR: Self-Insured

(This questionnaire applies only to the enrollment you are requesting a part time discount on)

At this time the Louisiana Patients' Compensation Fund offers discounts on the surcharge for health care providers who are not working full time. There are specific hour limits for the different levels of discount. Since you are currently requesting or receiving a discount, we ask that you provide specific information about your hours of work to verify that you qualify for the discount.

Please note that actual time spent with a patient is not the only part of patient care. If you are in the office you are not only seeing your patients but you are also noting the patient charts, reading patient x-rays, answering telephone calls in regards to the patient, etc.

Providers who work up to 35 hours per month (i.e. about 8 hours per week) may request a 75% discount.

Providers who work up to 65 hours per month (i.e. about 15 hours per week) may request a 50% discount.

Providers who work up to 85 hours per month (i.e. about 19 hours per week) may request a 25% discount.

My current practice involves (check all that apply):

direct patient care, chart review, patient calls, review of x-rays, review of lab results, etc.

surgery and/or invasive procedures

supervision of students, residents or fellows

supervision of Physician's Assistants, Nurse Practitioners or other provider extenders

peer review, utilization review, medical direction or other exercise of professional judgment which does not involve direct patient contact

dispensing of medications or medical equipment

other:

My current practice sites include (check all that apply):

If you work in multiple locations, please provide the name, location, job title and work schedule for each practice situation/location.

Please describe your current professional employment (all that apply)

I currently work a regular schedule of approximately hours per week, weeks per year.

I currently work on an as needed basis approximately hours per week, weeks per year.

I currently work temporary positions approximately hours per week, weeks per year.

I currently have work related coverage, but I wish to maintain personal professional liability coverage.

I am not currently working in patient care in Louisiana, but I wish to maintain professional liability coverage.

Discount request

Based on the schedule described above, and the PCF rate manual allowances for part-time discounts,

25% 50% 75%

By signing this statement, I am certifying that I am requesting coverage for the hours stated above and that my practice time does not exceed the allowable hours for this discount.

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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