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Applications & Forms
About Us
Contact

Rapid Quote

First Name(Required)

Last Name(Required)

Preferred Contact Method(Required)

Email(Required)

Phone(Required)

Specialty

Effective Date

MM slash DD slash YYYY

County

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Phone(Required)

Preferred Day or Time(Required)

Physician & Contact Information

Physician or Group Name(Required)

County or Counties of Practice(Required)

Contact Person(Required)

Phone(Required)

Fax

Email(Required)

Policy Information

Expiration Date

MM slash DD slash YYYY

Current carrier(Required)

Are you currently licensed or have you ever been licensed to practice Medicine outside of the state of Missouri?(Required)

Yes

No

Please list each state in which you have been licensed(Required)

Requested Limits(Required)

500/1M

1M/3M

List each physician and requested information on each(Required)

Physician (First name, M.I., Last name)

Start Date in Medical Practice

Specialty

Retroactive Date Requested

Hours Worked (per week)

Invasive Surgery? (Yes or No)

Claim History

Have you or any doctor in the group ever had a claim filed against you?(Required)

Yes

No

Please complete the following(Required)

Physician (Name, M.I., Last Name)

Date of Incident

Claim Status

Amount of Settlement/Verdict

(Claim status means it is either: Pending, Closed, Dismissed, Settled or Verdict.)

Pain Medication Questionnaire

Do you prescribe pain medications?(Required)

Yes

No

Are you a pain management physician?(Required)

Yes

No

Do you prescribe opioids?(Required)

Yes

No

If yes: What pain medications do you prescribe? (list all medications)

What purpose, i.e. diagnosis?

Do you manage long term pain medications?(Required)

Yes

No

Approximately how many patients do you treat for pain with opioid treatment annually ?

Do you prescribe methadone?(Required)

Yes

No

When CONSIDERING long–term opioid therapy, do you?

Set realistic goals for pain and function based on diagnosis (eg. walk around the block).(Required)

Always

Never

Sometimes

Check that non–opioid therapies tried and optimized.(Required)

Always

Never

Sometimes

Discuss benefits and risks (eg. addiction, overdose) with patient.(Required)

Always

Never

Sometimes

Evaluate risk of harm or misuse.(Required)

Always

Never

Sometimes

Discuss risk factors with patient.(Required)

Always

Never

Sometimes

Check urine drug screen.(Required)

Always

Never

Sometimes

Set Criteria for stopping or continuing opioids.(Required)

Always

Never

Sometimes

Assess baseline pain and function (eg. PEG scale).(Required)

Always

Never

Sometimes

Prescribe short–acting opioids using lowest dosage on product labeling; match duration to scheduled reassessment.(Required)

Always

Never

Sometimes

If RENEWAL without patient visit, do you?

Check that return visit is scheduled < 3 months from last visit.(Required)

Always

Never

Sometimes

When REASSESSING at return visit, do you?

Continue opioids only after confirming clinically meaningful improvements in pain and function without significant risks or harm.(Required)

Always

Never

Sometimes

Assess pain and function (eg. PEG); compare results to baseline.(Required)

Always

Never

Sometimes

Evaluate risk of harm or misuse:(Required)

Always

Never

Sometimes

Observe patient for signs of over–sedation or overdose risk.(Required)

Always

Never

Sometimes

If yes: Do you taper dose.

Always

Never

Sometimes

Check for opioid use disorder if indicated (eg. difficulty controlling use)(Required)

Always

Never

Sometimes

If yes: Do you Refer for Treatment.

Always

Never

Sometimes

Check that non–opioid therapies optimized.(Required)

Always

Never

Sometimes

Determine whether to continue, adjust, taper, or stop opioids.(Required)

Always

Never

Sometimes

Calculate opioid dosage morphine milligram equivalent (MME).(Required)

Always

Never

Sometimes

If > 50 MME/day total (> 50mg hydrocodone; > 33mg oxycodone), Increase frequency of follow–up; consider offering nalozone.

Always

Never

Sometimes

Avoid > 90 MME/day total (> 90mg hydrocodone; > 60mg oxycodone), Or carefully justify; consider specialist referral.

Always

Never

Sometimes

Schedule reassessment at regular intervals (< 3 months).(Required)

Always

Never

Sometimes

Signature(Required)

Date

MM slash DD slash YYYY

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All references to MODOCS refer to Missouri Doctors Mutual Insurance Company,
601 Francis Street, Saint Joseph, MO 64501