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AH PAIN MANAGEMENT SUPPLEMENT

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Page 1 of 4
Clinic or Surgery Center Application
PAIN MANAGEMENT SUPPLEMENT
MUST
Instructions to the Applicant – please complete this application in ink and answer all questions completely. Attach extra sheets as
necessary should you run out of space provided. An incomplete or illegible application cannot be processed. Completion of this
application neither binds coverage nor guarantees that a policy will be issued.
also be completed
GENERAL INFORMATION AND OPERATIONS
1. Full name of Applicant (Including DBA’s) _________________________________________________________________
2. Applicant’s practice is operated by:
Nurse Nurse Practitioner Physician Assistant Dentist Other Individual: ________________________
Physician or Surgeon (specify specialty: ___________________________________)
Certified by the American Board of Pain Medicine
Certified by the American Board of Interventional Pain Physicians
Certified by other pain sub-specialty Board or Academy (specify:__________________________________________________)
Training Completed Related to the Sub-Specialty of Pain Management (attach a copy of all certificates)
=
3. Percentage of practice devoted to Pain Management: _____%
4.
Age Range of Clients: _____% Under 18 _____% 18-39 _____% 40-65 _____% Over 65
5.
Do you require ALL
_______________________________________________________________________________
patients to sign an Informed Consent form prior to any procedure being
performed? If Yes, please attach copies of patient informed consents. If No, please explain.
_______________________________________________________________________________
_______________________________________________________________________________
Yes No
6.
If any clients are under the age of 18 – do you require parent/guardian signatures on Informed
Consents? Please indicate all procedures performed on clients under the age of 18 if applicable:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Yes No N/A
7.
Do you require a referral from a current treating physician?
Yes No
8. Do you accept walk-ins?
Yes No
9. List the diagnostic procedures (i.e., EMG, MRI, etc) employed to centralize the source and
measure the severity of pain.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
10. Do you prescribe narcotics? If Yes please attach copy of protocol in place for administration
and monitoring of drug use AND a copy of the narcotic-specific Informed Consent form.
Yes No
11. Describe how you monitor and treat a patient’s depression throughout the course of treatment.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
12. Please indentify the particular clinical practice guidelines adopted for your practice – indicate here if “none”
American Pain Society
American Society of Anesthesiologists
American Academy of Family Physicians
Other: ___________________________________________________
13. SERVICES:
Yes?
Procedures
# Annually
PA
DDS / DMD
MD / DO
OTHER (must specify name and designation)
Hypnosis
Acupuncture
Physical Therapy
Prescription Medication
Only
Trigger Point Injections
MYBLOC/BOTOX Injections
Epidural Injections
Lumbar Sympathetic Nerve
Blocks
Intercostal Nerve Blocks
Sacroiliac Joint Injections
Facet Nerve Blocks
Stellate Ganglion Blocks
Other Nerve Blocks: (Type)
_____________________
_____________________
_____________________
Transcutaneous Electric
Nerve Stimulation (TENS)
Spinal Endoscopy
IntraDiscal Electric Thermal
Therapy
Radio Frequency Nerve
Ablation
Bioelectric Treatment
Celiac Hypogastric Plexus
Injections
Spinal Cord Stimulation
Implantable Pain Control
Devices: (Type)
_____________________
_____________________
Percutaneous Disc
Decompression
Vertebroplasty
Cryoanalgesia
Neurolytic Lysis of
Adhesions
Other: (Type)
_____________________
Other: (Type)
_____________________
Page 3 of 4
14. Have all staff performing procedures noted on the previous page received required training and/or
certification specific to the indicated procedure including anatomy, physiology, technique,
potential complications, appropriate responses to complications, and hands-on performance of at
least one procedure on a live patient? Please attach evidence of training for procedures noted.
Yes No
15.
Does the applicant or staff utilize or perform any procedures, drugs, or equipment that is not
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
approved for use by the FDA? If yes, please explain:
Yes No
16.
Does the applicant or staff engage in any off label use
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
of otherwise FDA approved procedures,
drugs, or equipment? If yes, please explain:
Yes No
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS, MARYLAND,
MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA, NORTH DAKOTA,
OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND WYOMING
APPLICANTS: In some states, any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance or
statement of claim containing any materially false information, or, for the purpose of misleading, conceals information concerning any fact material thereto, may
commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance
company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to
the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the
insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to
a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a
crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal
and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or other person 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,
Page 4 of 4
commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such
violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files
a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application for
insurance or statement of a 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 and subjects the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the above
statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit any material
facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective date of any
policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn based upon such
changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this application and
made a part of this application.
Applicant: _____________________________________ Title: ________________________________
FEIN #: _____________________________________
Applicant’s Signature: ___________________________ Date: ________________________________
Agent / Broker Name: _____________________________________________________________________
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AH PAIN MANAGEMENT SUPPLEMENT

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Completed 2 July 2020

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