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Georgia uniform healthcare practitioner credentialing application form professional liability claims information form


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Schedule B

Claim     of    


GEORGIA UNIFORM HEALTHCARE PRACTITIONER

CREDENTIALING APPLICATION FORM
PROFESSIONAL LIABILITY CLAIMS INFORMATION FORM
The following information is necessary to complete the credentialing verification process and will be kept confidential. Please print or type answers to the following for any malpractice claims reported to your malpractice insurance carrier, opened, closed, settled or paid. For initial credentialing, please complete a separate form for each claim; for recredentialing, just complete forms for the last ten (10) years. One case per sheet (please photocopy if additional sheets are needed).


PROVIDER’S NAME:

(Required even if N/A)

     

Does Not Apply 

Note: Signature Required even if checked.




Name of Patient Involved

Age

Month and Year of Occurrence

(Event precipitating claim)

Month and Year of Lawsuit

Insurance Carrier at Time

     

   

  /    

  /    

     




What is/was your status?

List other defendants:


 Primary Defendant  Co-Defendant

 Other, please explain:      



     




What was the patient’s outcome?


     




How were you alleged to have caused harm or injury to this patient?


     




Please provide specifics in reference to the adverse event:


     




What is/was your role in this event?

     





CURRENT STATUS

 Still pending (as of) Date:   /    

Who is handling the defense of the case?      

 Trial date set - awaiting trial

Trial Date:   /    

 Dismissed

Date of Dismissal:   /    

 Defense Verdict

Date of Defense Verdict:   /    

 Settled out of court

Date:   /    

Total Amount of Settlement:

$      

Amount Paid by You:

$      

 Judgment

Date:   /    

Total Amount of Judgment:

$      

Amount Paid by You:

$      

This Professional Liability Claims Information Form is required on all claims/lawsuits that are reported by your malpractice insurance carrier and/or the National Practitioner Data Bank. Clinical details are required for all suits, regardless of status or settlement amount.
I certify that the information contained in this form is correct and complete (even if N/A) to the best of my knowledge.


Signature:

(Required)






Date:







07/28/2003 Georgia Uniform Healthcare Practitioner Credentialing Application Form Schedule B


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