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TELERADIOLOGY (Kinsale Insurance)

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Kinsale Insurance Company
P.O. Box 17008
Richmond, VA 23236
(804) 289-1300
www.kinsaleins.com
Instructions to the Applicant: Please complete this supplement in ink and answer all questions completely. Attach extra
sheets as necessary should you run out of space provided. An incomplete or illegible supplement cannot be processed.
TELERADIOLOGY SUPPLEMENT
PERSONAL INFORMATION
Applicant’s Name: ___________________________________________________________________
MD DO
EDUCATION AND TRAINING
1. Are you currently certified by the American Board of Radiology?
If yes, which certification(s) do you hold? ______________________________________________
YES
NO
2. Are you in compliance with ACR guidelines with respect to the following key teleradiology
recommendations:
• Do you hold a valid medical license or a state-issued special purpose medical license in all
jurisdictions for which images are transmitted to you for radiologic interpretation?
• Are you credentialed by every institution from which you receive images for radiologic
interpretation?
3. How long have you been practicing teleradiology? _________________________
YES NO
YES NO
PRACTICE LOCATIONS/PROCEDURES
4. What percentage of your practice is dedicated to teleradiology services outside of the state of your
primary practice location? __________%
5. Indicate the state(s) where you will provide teleradiology services and the percentage in each state: ___________
_______________________________________________________________________________________________
6. Please identify the type(s) of teleradiology reads you perform (check all that apply)
Type of Read
Plain Radiography
Fluoroscopy
Angiograph
Ultrasound
Computed tomography
Mammography
Nuclear Medicine
MRI
Other(s) _________________
Percentage of Read
Type(s)
________________
________________
________________
________________
________________
________________
________________
________________
________________
# of Reads Last 12
Months
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
# of Reads Next 12
Months
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
7. Of the total number of reads noted above, please indicate the percentage of those that are final reads __________%
AUTHORIZATION AND SIGNATURE
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 fact.
Signature: ___________________________________________________________________ Date: ________________
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TELERADIOLOGY (Kinsale Insurance)

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Completed 20 July 2020

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