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SUPPLEMENT FOR MEDICAL SPAANTI-AGING CLINICS (USE WITH

By Angela Morris,2014-06-28 10:54
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SUPPLEMENT FOR MEDICAL SPAANTI-AGING CLINICS (USE WITH ...

    SUPPLEMENT FOR MEDICAL SPA/ANTI-AGING CLINICS

    (USE WITH APPLICATION FOR CLINICS (MEDICAL, PUBLIC HEALTH, DENTAL, ETC.)

    PROFESSIONAL LIABILITY INSURANCE (SM-30006))

    All questions MUST be completed in full.

    If space is insufficient to answer any question fully, attach a separate sheet.

I. GENERAL INFORMATION

    1. Full name of Applicant: II. OPERATIONS

    1. What is the professional specialty of the clinic?

    2. (a) Provide a list of the Applicant’s Medical Director(s):

     (b) Attach a CV for each of the Applicant’s Medical Directors and a description of their duties. 3. Provide the percentage of the Applicant’s patients/clients in the following categories:

    (a) Acupuncture % Plastic Surgery _____%

     Beauty Shop (nails, hair, facials) % Research or Experimental _____%

     Chelation Therapy % Sclerotherapy _____%

    Dental % Surgical _____%

    Dermatology % Weight Control _____%

    Hormone Therapy % Other (specify)

    Massage % _____%

    Medical Spa % TOTAL 100%

    4. Applicant’s practice is run by:

     Doctor Plastic Surgeon Other describe

     Dentist Nurse

     Dermatologist Administrator

    III. PROFESSIONAL SERVICES

    1. List all manufactured equipment and drugs used in the Applicant’s practice and the purpose for which each is used.

    Attach separate sheet if necessary:

    Used only as

    approved by the

    Equipment/Drug Purpose FDA? (Yes or No) If No, describe off-label usage.

    2. Does the Applicant take before and after pictures of every patient? ........................................................ [ ] Yes [ ] No

     If No, explain.

3. Must all clients sign a patient consent form specific to the procedures to be performed prior to

    treatment? ........................................................................................................................................... [ ] Yes [ ] No

     If No, explain. SM-31001-02 03/07 Page 1 of 5

IV. PROCEDURES

    1. Botox Injections

     Does the Applicant perform Botox Injections? ...................................................................................... [ ] Yes [ ] No

     If Yes, complete the following:

     (a) Total number of Botox Injections: ....................................... (i) Past 12 months: _____ (ii) Next 12 months: _____

     (b) Who performs Botox Injections? .............................................................................................................................

     Physician Physician’s Assistant Nurse

     Dentist Nurse Practitioner Other-describe:

    (c) Have all staff performing Botox Injections:

     (i) Received a minimum of eight hours training specific for this procedure including anatomy,

    physiology, technique, potential complications, appropriate responses to complications, and

    hands-on performance of at least one procedure on a live patient? .......................................... [ ] Yes [ ] No

     (ii) Performed a minimum of ten procedures on live patients? ....................................................... [ ] Yes [ ] No

    (d) Does the Applicant have a physician available for consultation and complications? .......................... [ ] Yes [ ] No

     If Yes,

     (i) Has this physician completed a minimum of eight hours training specific for this procedure

    including anatomy, physiology, technique, potential complications, appropriate responses to

    complications, and hands-on performance of at least one procedure on a live patient? ............. [ ] Yes [ ] No

     (ii) Does the physician have Medical Malpractice Liability Insurance for this activity? .................... [ ] Yes [ ] No

     If No, submit a separate application for each physician to be included.

    2. Chemical Peels

     Does the Applicant perform Chemical Peels? ...................................................................................... [ ] Yes [ ] No

     If Yes, complete the following:

     (a) Total number of Chemical Peels with solution strength <30%: . (i) Past 12 months: _____ (ii) Next 12 months: _____

     (i) Who performs Chemical Peels with solution strength <30%:

     Physician Physician’s Assistant Nurse

     Dentist Nurse Practitioner Other-describe:

     (ii) Have all staff performing Chemical Peels with solution strength <30% received a minimum of

    eight hours training specifically for this procedure including anatomy, physiology, skin typing,

    technique, potential complications, appropriate responses to complications, and hands-on

    performance of at least one procedure on a live patient? ........................................................ [ ] Yes [ ] No

    (b) Total number of Chemical Peels with solution strength >30%: . (i) Past 12 months: _____ (ii) Next 12 months: _____

     (i) Who performs Chemical Peels with solution strength >30%:

     Physician Physician’s Assistant Nurse

     Nurse Practitioner Other-describe: Dentist

    (ii) Are all staff performing Chemical Peels with solution strength >30% licensed physicians with

    a specialty of Dermatology or Plastic Surgery? ........................................................................ [ ] Yes [ ] No 3. Dermal Fillers

     Does the Applicant perform Dermal Fillers (Artefill, Collagen, Hylaform, Restylane)? ............................. [ ] Yes [ ] No

     If Yes, complete the following:

     (a) Total number of Dermal Fillers: ........................................... (i) Past 12 months: _____ (ii) Next 12 months: _____

     (b) Who performs Dermal Fillers?

     Physician Physician’s Assistant Nurse

     Dentist Nurse Practitioner Other-describe:

     (c) Have all staff performing Dermal Fillers:

    (i) Received a minimum of eight hours training specific for this procedure including anatomy,

    physiology, technique, potential complications, appropriate responses to complications, and

    hands-on performance of at least one procedure on a live patient? ........................................ [ ] Yes [ ] No

     (ii) Performed a minimum of five procedures on live patients? ...................................................... [ ] Yes [ ] No

SM-31001-02 03/07 Page 2 of 5

     Dermal Fillers continued

     (d) Does the Applicant have a physician available for consultation and complications? ......................... [ ] Yes [ ] No

     If Yes,

     (i) Has this physician completed a minimum of eight hours training specific for this procedure

    including anatomy, physiology, technique, potential complications, appropriate responses to

    complications, and hands-on performance of at least one procedure on a live patient? ............ [ ] Yes [ ] No

     (ii) Does this physician have Medical Malpractice Liability Insurance for this activity? .................... [ ] Yes [ ] No

     If No, submit a separate application for each physician to be included.

     (e) Does the Applicant

     (i) Use only dermal fillers approved by the FDA? ........................................................................ [ ] Yes [ ] No

     If No, explain:

    (ii) Disclose off-label use to all patients receiving such treatment on the patient consent form? ..... [ ] Yes [ ] No

    4. Laser Skin Treatments

     Does the Applicant perform Laser Skin Treatments including Laser Hair Removal, IPL (Intense Pulse

    Light Treatments), Acne Blue Light Treatments, and Laser Vein Treatments? ...................................... [ ] Yes [ ] No

     If Yes, complete the following:

     (a) Total number of Laser Skin Treatments: ............................. (i) Past 12 months: _____ (ii) Next 12 months: _____

     (b) Who performs Laser Skin Treatments Injections?

     Physician Physician’s Assistant Nurse

     Dentist Nurse Practitioner Other-describe:

     (c) Does the Applicant comply with the following standards of practice:

     (i) Individuals are trained in laser physics, tissue interaction, laser safety, clinical application, pre-

    operative care, and post-operative care of the laser patient. ...................................................... [ ] Yes [ ] No

     (ii) Prior to the initiation of any patient care activity the individual has read and sign the clinics

    policies and procedures regarding the safe use of lasers. ......................................................... [ ] Yes [ ] No

     (iii) Continuing education of all licensed medical professionals is mandatory and made available

    with reasonable frequency (including outside the office setting) to help insure adequate

    performance. (Specific credit hour requirements will be determined by the state and/or

    individual clinic.) ..................................................................................................................... [ ] Yes [ ] No

     (iv) A minimum of ten procedures of precepted training is required for each laser procedure and

    laser type to assess competency. Participation in all training programs, acquisition of new skills

    and number of hours spent in maintaining proficiency is well documented. ................................ [ ] Yes [ ] No

     (v) After demonstrating competency to act alone, the designated licensed medical professional

    may perform limited laser treatments on specific patients as directed by the supervising

    physician. ............................................................................................................................... [ ] Yes [ ] No

     (d) Does the Applicant comply with the following standards of practice for non-physicians use of laser

    related technology:

     (i) Any physician who delegates a procedure to a non-physician must be qualified to do these

    laser procedures themselves by virtue of having received appropriate training in physics,

    safety, surgical techniques, pre and post operative care, and be able to handle the resultant

    emergencies or sequela........................................................................................................... [ ] Yes [ ] No

     (ii) Any licensed medical professional employed by a physician to perform a procedure has

    received appropriate documented training and education in the safe and effective use of each

    system and are a licensed medical professional in the state of practice. .................................... [ ] Yes [ ] No

     (iii) A properly trained and licensed medical professional carries out these specifically designed

    procedures only under the direct, on-site physician supervision and following written

    procedures. ............................................................................................................................ [ ] Yes [ ] No

     (iv) The supervising physician is available on-site to respond to any untoward event that may

    occur. Ultimate responsibility lies with the supervising physician. ............................................... [ ] Yes [ ] No 5. Massage Therapy/Cellulite Treatments

     Does the Applicant perform Massage Therapy/Cellulite Treatments? .................................................... [ ] Yes [ ] No

     If Yes, complete the following:

     (a) Total number of Massage Therapy / Cellulite Treatments: .... (i) Past 12 months: _____ (ii) Next 12 months: _____

     (b) Who performs Massage Therapy / Cellulite Treatments?

     Physician Physician’s Assistant Nurse

     Massage Therapist Nurse Practitioner Other-describe:

    SM-31001-02 03/07 Page 3 of 5

    Massage Therapy/Cellulite Treatments continued

    (c) Are all staff performing Massage Therapy / Cellulite Treatments licensed, registered or certified

    according to state requirements? ................................................................................................... [ ] Yes [ ] No

    If No, explain. 6. Mesotherapy and/or Lipodissolve

     Does the Applicant perform Mesotherapy and/or Lipodissolve at this clinic? ......................................... [ ] Yes [ ] No

     If Yes, complete the following:

     (a) Total number of Mesotherapy/Lipodissolve Treatments: ....... (i) Past 12 months: _____ (ii) Next 12 months: _____

     (b) Who performs Mesotherapy/Lipodissolve at this clinic?

     Physician Physician’s Assistant Nurse

     Dentist Nurse Practitioner Other-describe:

    (c) Are all staff performing Mesotherapy and/or Lipodissolve licensed physicians with a minimum of

    eight hours training to perform Mesotherapy and/or Lipodissolve including anatomy, physiology,

    contraindications, potential complications, and performance of at least one procedure on each part

    of the anatomy for which coverage is desired? ................................................................................ [ ] Yes [ ] No 7. Microdermabrasions

     Does the Applicant perform Microdermabrasions? ............................................................................... [ ] Yes [ ] No

     If Yes, complete the following:

     (a) Total number of Microdermabrasions: ................................. (i) Past 12 months: _____ (ii) Next 12 months: _____

     (b) Who performs Microdermabrasion:

     Physician Physician’s Assistant Nurse

     Dentist Nurse Practitioner Other-describe:

    (c) Have all staff performing Microdermabrasion treatments received a minimum of eight hours training

    including specific training for the equipment being used, skin typing, contraindications, potential

    complications, and performance of at least one procedure on a live patient? ................................... [ ] Yes [ ] No

     If No, explain: 8. Micropigmentation / Permanent Makeup

     Does Applicant perform Micropigmentation / Permanent Makeup? ........................................................ [ ] Yes [ ] No

     If Yes, complete the following:

     (a) Total number of Permanent Makeup / Micropigmentations: .. (i) Past 12 months: _____ (ii) Next 12 months: _____

     (b) Who performs Permanent Makeup / Micropigmentations:

     Physician Physician’s Assistant Nurse

     Dentist Nurse Practitioner Other-describe:

    (c) Have all staff performing Permanent Makeup / Micropigmentation treatments received a minimum of

    eight hours training including specific training for the equipment being used, skin typing,

    contraindications, potential complications, and performance of at least one procedure on a live

    patient? ........................................................................................................................................ [ ] Yes [ ] No

     If No, explain: 9. Sclerotherapy Injections

     Does the Applicant perform Sclerotherapy Injections? .......................................................................... [ ] Yes [ ] No

     If Yes, complete the following:

     (a) Total number of Sclerotherapy Injections: ............................ (i) Past 12 months: _____ (ii) Next 12 months: _____

     (b) Who performs Sclerotherapy Injections?

     Physician Physician’s Assistant Nurse

     Dentist Nurse Practitioner Other-describe:

     (c) Are all staff performing Sclerotherapy Injections physicians who have received a minimum of eight

    hours training specific for this procedure, including anatomy, physiology, technique, potential

    complications, appropriate responses to complications, and hands-on performance of a minimum

    of one procedure on a live patient? ................................................................................................ [ ] Yes [ ] No

SM-31001-02 03/07 Page 4 of 5

10. Tattoo Removals

     Does the Applicant perform Tattoo Removals? ..................................................................................... [ ] Yes [ ] No

     If Yes, complete the following:

     (a) Total number of Tattoo Removals: ...................................... (i) Past 12 months: _____ (ii) Next 12 months: _____

     (b) Who performs Tattoo Removal:

     Physician Physician’s Assistant Nurse

     Dentist Nurse Practitioner Other-describe:

     (c) Are all staff performing Tattoo Removal licensed physicians who comply with the following standards of practice:

     (i) Physicians are trained appropriately in laser physics, tissue interaction, laser safety, clinical

    application, pre-operative care, and post-operative care of the laser patient. .............................. [ ] Yes [ ] No

     (ii) Prior to the initiation of any patient care activity the physician has read and signed the clinic’s

    policies and procedures regarding the safe use of lasers........................................................... [ ] Yes [ ] No

     (iii) Continuing education of all physicians is mandatory and made available with reasonable

    frequency (including outside the office setting) to help insure adequate performance. (Specific

    credit hour requirements will be determined by the state and/or individual clinic.) ...................... [ ] Yes [ ] No 11. Surgical or Minor Surgical / Invasive Procedures

     Does the Applicant perform surgical or minor surgical/invasive procedures? .......................................... [ ] Yes [ ] No

     If Yes, complete the following:

     (a) Total number of surgical procedures: ................................... (i) Past 12 months: _____ (ii) Next 12 months: _____

     (b) Who performs surgical and/or minor surgical/invasive procedures?

     (c) Provide a complete list of all surgical and minor surgical/invasive procedures being performed:

     Attach a separate sheet if necessary.

Signing this Supplement does not bind the Company to provide or the Applicant to purchase the insurance.

    It is understood that information submitted herein becomes a part of our application for insurance and is subject to the same

    declarations, representations and conditions.

    Must be signed by director, executive officer, partner or equivalent within 60 days of the proposed effective date.

Name of Applicant Title (Officer, partner, etc.)

Signature of Applicant Date

    SM-31001-02 03/07 Page 5 of 5

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