PI-PLSP-MTSUPP (04/10) Page 1 of 3
COVER-PRO
SM
APPLICATION
MEDICAL TRANSCRIPTIONIST SERVICE SUPPLEMENT
1. Full name of the Applicant Firm:
2. Advise the Applicant’s post secondary training relating to the medical transcription field:
3. Is the Applicant
a:
Registered Medical Transcriptionist (RMT)
Certified Medical Transcriptionist (CMT)
Provide a list of all other relevant certifications, designations, and accreditations:
4. How many years has the Applicant been transcribing medical records: Years
5. Describe the controls and procedures the Applicant uses when transcribing to ensure
proper editing, grammar, and accurate identification and usage of medical terminology:
6. Does the Applicant provide record storage or document management services for a third
party? If yes, please provide the security controls in place.
Yes No
7.
Does the Applicant have HIPAA (Health Insurance Portability and Accountability Act of
1996
) compliance procedures in place? If yes, describe all procedures. Yes No
8. If working in a doctor’s office, hospital or other medical setting, does the Applicant perform
services other than medical transcription (i.e. scheduling appointments, answering
phones)? If yes, describe all services. N/A
Yes
No
9. Does the Applicant perform transcription services for a medical specialty or field (i.e.
radiology, pathology)? If yes, list all specialties and years of field experience for each.
Yes
No
