Allied Health Care Miscellaneous Supplement Allied Health Care Miscellaneous Supplement APP PDF Download Allied Health Care - Miscellaneous Supplement Complete the following only for the professions for which you are applying for coverage. Professions not listed here may require a separate supplemental applicationName of Applicant:* Prefix First Last Suffix A. Dental Assitant1) Does the applicant work under a dentist's supervision?* Yes No 2) Does the applicant administer general or sedative anesthesia? (do not answer "Yes" if local anesthesia only)* Yes No B. Dental Hygienist1) Does the applicant work under a dentist's supervision?* Yes No 2) Does the applicant administer general or sedative anesthesia? (do not answer "Yes" if local anesthesia only)* Yes No C. EEG Technician/Technologist1) Is the applicant CPR certified or have CPR certified staff on duty?* Yes No 2) What percentage of services involves pediatric patients?*10%20%30%40%50%60%70%80%90%100%D. First Aid/CPR Training1) Does the applicant provide services creating evacuation plans or compliance with fire/safety regulations?* Yes No 2) Does the applicant provide training other than first aid/CPR?* Yes No 3) Does the applicant specialize in consulting services for earthquake, terrorism, weapons of mass destruction or similar catastrophic events?* Yes No E. Health Educator1) Does the applicant provide abortion counseling, adoption screening or foster care screening?* Yes No 2) Does the applicant specialize in emergency preparedness/catastrophic/mass epidemic consulting?* Yes No F. Lactation Consultant1) Does the applicant specialize in consulting for premature infants?* Yes No G. Medical Office Assistant1) Does the applicant provide services as a Physicians Assistant?* Yes No 2) Is the applicant involved in utilization review, peer review/case management services or making managed care treatment decisions?* Yes No 3) Does the applicant provide clinical services including medical treatment, prepare/administer medication, remove sutures or assist in physical exams?* Yes No H. Opticians & Optometric Assistants1) Does the applicant provide any services as an ophthalmologist or optometrist?* Yes No 2) Does the applicant fit prosthetic ocular devices?* Yes No I. Patient Intake Technician1) Does the applicant provide peer review/case management services, make managed care treatment decisions or provide utilization review services?* Yes No 2) Does the applicant work in an emergency room?* Yes No J. Speech Language Pathologist1) Does the applicant perform suctioning or emergency procedures?* Yes No This supplemental application is incorporated into and is deemed a apart 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.Name of Applicant:* (Please type full name in space provided)Title:* 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.) Date:* MM slash DD slash YYYY Producer Name:* Retail Agency Name:* 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.) CommentsThis field is for validation purposes and should be left unchanged.