Allied Health Care - Athletic, Physical Trainer and Theraist Supplement Allied Health Care – Athletic, Physical Trainer and Theraist Supplement APP PDF Download Allied Health Care - Athletic, Physical Trainer and Theraist Supplement PLEASE INDICATE ALL SERVICES PROVIDED BY THE APPLICANT: Athletic Trainers Physical Therapists Personal Trainers/Fitness Instructors Occupational Therapists Corrective Therapists Rehabilitation Therapists 1) Name of Applicant:* Prefix First Last Suffix 2) Does the Applicant provide any services involving Thai Massage?*YesNo3) Percentage of services provided to minors (3-18 yrs):*10%20%30%40%50%60%70%80%90%100%4) Does any person for whom coverage is sough conduct blood analysis or stress testing services?*YesNo5) Does any person for whom coverage is sough provide integumentary services (wound/burns) or services to children under age three?*YesNo6) Does any person for whom coverage is sought work with celebrities, professional athletes, Division 1 college athletes or recruits or other high profile clients?*YesNoIf "Yes", % of services for high profile clients?10%20%30%40%50%60%70%80%90%100%7) If applicant is an athletic trainer or provides physical therapy services, are these services provided only under a physician's direction?YesNoIf "No", please explain:8) (a) If physical therapy services are provided, are formal policies and procedures followed for assessing quality of care, risk management, infection control and patient safety?*YesNoN/A(b) If "Yes", are these policies and procedures reviewed for effectiveness?YesNo9) Does the applicant provide more than 10% of services in a nursing home or inpatient hospital setting?*YesNo10) If physical therapy services are provided, does the applicant follow formal policies and procedure for proper documentation of patient/client records and proper communication of clinical information to professionals involved in the treatment of patients/clients?*YesNo11) Does the applicant own/operate a training, therapy or fitness facility?*YesNoN/A(a) If "Yes", are safety inspections regularly performed on the facility and all equipment?YesNoN/A12) If the applicant is a corrective therapist, are all services performed only with a physicians order?*YesNoN/A13) If the applicant provides occupational therapy services, do these services include drive rehabilitation services?*YesNoN/A14) If the applicant provides occupational therapy services, does the applicant require a physician's sign-off before a patient/client returns to work?*YesNoN/A15) If applicant is a personal trainer, are martial arts or combat training services offered?*YesNoN/A16) Does the applicant require signed informed consent and waiver of liability forms for all patients/clients (parent or guardian signing for minors)?*YesNoThis supplemental application is incorporated into and is deemed a part of the other application(s) submitted in connection with the requested insurance. Any and all notices and representations included in such other application(s) are incorporated by reference in this supplemental application as though fully set forth herein.Applicant's Signature*(Principal, Partner or Officer) (Please use your mouse on a PC or Mac, or your finger or stylus on a tablet or smartphone to sign your name.)Title:*Date:* Date Format: MM slash DD slash YYYY Producer Name:*Retail Agency Name:*Print Name:*(Please type full name in space provided)Agent's Signature*(Required in New Hampshire) (Please use your mouse on a PC or Mac, or your finger or stylus on a tablet or smartphone to sign your name.)PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
