Rural Medical Practitioners Insurance Subsidy Affidavit for NPs Your Information Full Name First Name Middle Name Last Name Email Address Office Phone Professional Specialty State of Oregon Medical License Number Are you employed by a licensed physician? Yes No Are you certified to provide Obstetric Care? Yes No Professional Liability Insurance Carrier - Select -Allied WorldCNA - Affinity Insurance ServiceCNA - Oregon Medical AssociationCoverysDarwin National Assurance CompanyMag MutualPhysicians InsurancePreferred Professional Insurance CompanyProSelectThe Doctors CompanyThe Medical Protective Insurance Company Policy Number Additional Professional Liability Insurance Carrier - None -Allied WorldCNA - Affinity Insurance ServiceCNA - Oregon Medical AssociationCoverysDarwin National Assurance CompanyMag MutualPhysicians InsurancePreferred Professional Insurance CompanyProSelectThe Doctors CompanyThe Medical Protective Insurance Company Policy Number CURRENT PRIMARY Practice Physical Address Primary Practice Name Primary Practice Address Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Average Work Week Hours (i.e. 40, 36, 20, etc.) Number of hours spent weekly in this location (please do not include time on call or travel time) Do you have a Secondary Practice? Yes No CURRENT SECONDARY Practice Physical Address Secondary Practice Name Secondary Practice Address Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Normal Work Week Hours Number of hours spent weekly in this location (please do not include time on call or travel time) Do you have Additional Practice Sites? Yes No Additional Practice Sites Please list additional practices I agree I attest that I am willing to serve Medicare and Medicaid patients in at least the same proportion to the total number of my patients as the Medicare and Medicaid populations represent to the total number of people in the rural areas of the county in which I practice. I hereby certify that all information supplied in this affidavit is accurate to the best of my knowledge. I understand that if my practice location or insurance carrier changes, I must notify the Office of Rural Health within 10 days of the change so that a determination can be made regarding my continued eligibility for this benefit. Leave this field blank
Rural Medical Practitioners Insurance Subsidy Affidavit for NPs Your Information Full Name First Name Middle Name Last Name Email Address Office Phone Professional Specialty State of Oregon Medical License Number Are you employed by a licensed physician? Yes No Are you certified to provide Obstetric Care? Yes No Professional Liability Insurance Carrier - Select -Allied WorldCNA - Affinity Insurance ServiceCNA - Oregon Medical AssociationCoverysDarwin National Assurance CompanyMag MutualPhysicians InsurancePreferred Professional Insurance CompanyProSelectThe Doctors CompanyThe Medical Protective Insurance Company Policy Number Additional Professional Liability Insurance Carrier - None -Allied WorldCNA - Affinity Insurance ServiceCNA - Oregon Medical AssociationCoverysDarwin National Assurance CompanyMag MutualPhysicians InsurancePreferred Professional Insurance CompanyProSelectThe Doctors CompanyThe Medical Protective Insurance Company Policy Number CURRENT PRIMARY Practice Physical Address Primary Practice Name Primary Practice Address Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Average Work Week Hours (i.e. 40, 36, 20, etc.) Number of hours spent weekly in this location (please do not include time on call or travel time) Do you have a Secondary Practice? Yes No CURRENT SECONDARY Practice Physical Address Secondary Practice Name Secondary Practice Address Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Normal Work Week Hours Number of hours spent weekly in this location (please do not include time on call or travel time) Do you have Additional Practice Sites? Yes No Additional Practice Sites Please list additional practices I agree I attest that I am willing to serve Medicare and Medicaid patients in at least the same proportion to the total number of my patients as the Medicare and Medicaid populations represent to the total number of people in the rural areas of the county in which I practice. I hereby certify that all information supplied in this affidavit is accurate to the best of my knowledge. I understand that if my practice location or insurance carrier changes, I must notify the Office of Rural Health within 10 days of the change so that a determination can be made regarding my continued eligibility for this benefit. Leave this field blank