Rural Medical Practitioners Insurance Subsidy Affidavit for NPs

Your Information

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

Are you certified to provide Obstetric Care?

Yes

Professional Liability Insurance Carrier

Policy Number

Additional Professional Liability Insurance Carrier

Policy Number

CURRENT PRIMARY Practice Physical Address

Primary Practice Name

Address

City/Town

State/Province

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

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.

Oregon Office of Rural Health

Oregon Office of Rural Health

Rural Medical Practitioners Insurance Subsidy Affidavit for NPs

Your Information

CURRENT PRIMARY Practice Physical Address

CURRENT SECONDARY Practice Physical Address