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?*YesNo2) Does the applicant administer general or sedative anesthesia? (do not answer "Yes" if local anesthesia only)*YesNoB. Dental Hygienist1) Does the applicant work under a dentist's supervision?*YesNo2) Does the applicant administer general or sedative anesthesia? (do not answer "Yes" if local anesthesia only)*YesNoC. EEG Technician/Technologist1) Is the applicant CPR certified or have CPR certified staff on duty?*YesNo2) 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?*YesNo2) Does the applicant provide training other than first aid/CPR?*YesNo3) Does the applicant specialize in consulting services for earthquake, terrorism, weapons of mass destruction or similar catastrophic events?*YesNoE. Health Educator1) Does the applicant provide abortion counseling, adoption screening or foster care screening?*YesNo2) Does the applicant specialize in emergency preparedness/catastrophic/mass epidemic consulting?*YesNoF. Lactation Consultant1) Does the applicant specialize in consulting for premature infants?*YesNoG. Medical Office Assistant1) Does the applicant provide services as a Physicians Assistant?*YesNo2) Is the applicant involved in utilization review, peer review/case management services or making managed care treatment decisions?*YesNo3) Does the applicant provide clinical services including medical treatment, prepare/administer medication, remove sutures or assist in physical exams?*YesNoH. Opticians & Optometric Assistants1) Does the applicant provide any services as an ophthalmologist or optometrist?*YesNo2) Does the applicant fit prosthetic ocular devices?*YesNoI. Patient Intake Technician1) Does the applicant provide peer review/case management services, make managed care treatment decisions or provide utilization review services?*YesNo2) Does the applicant work in an emergency room?*YesNoJ. Speech Language Pathologist1) Does the applicant perform suctioning or emergency procedures?*YesNoThis 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:* Date Format: 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.) EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.