First Name(Required)Last Name(Required)Preferred Contact Method(Required)EmailPhoneEmail(Required) Phone(Required)SpecialtyNo ValueAllergyAnesthesiologyCardiologyCardiovascular SurgeryDermatologyEmergency MedicineEndocrinologyFamily PracticeFamily Practice w/obFamily Practice w/surgeryGastroenterologyGeneral SurgeryGeriatricsGynecologyHematology/OncologyInfectious DiseaseIntensive CareInternal MedecineMedical DirectorshipsNephrologyNeurological SurgeryNeurologyNutritionOb/GynOccupational MedicineOncologyOphthalmologyOptometryOral SurgeonOrthopedic SurgeryOsteopathic ManipulationOtorhinolaryngologyPain ManagementPathologyPediatricsPhysiatryPhysician NOCPlastic SurgeryPodiatryPsychiatryPsychiatry w/ECTPublic HealthPulmonary DiseaseRadiologyRadiology/TherapyRheumatologySurgeonThoracic SurgeryTraumatic SurgeryUrgent CareUrologyVascular SurgeryEffective Date MM slash DD slash YYYY CountyNo ValueAdairAndrewAtchisonAudrainBarryBartonBatesBentonBollingerBooneBuchananButlerCaldwellCallawayCamdenCape GirardeauCarrollCarterCassCedarCharitonChristianClarkClayClintonColeCooperCrawfordDadeDallasDaviessDeKalbDentDouglasDunklinFranklinGasconadeGentryGreeneGrundyHarrisonHenryHickoryHoltHowardHowellIronJacksonJasperJeffersonJohnsonKnoxLacledeLafayetteLawrenceLewisLincolnLinnLivingstonMaconMadisonMariesMarionMcDonaldMercerMillerMississippiMoniteauMonroeMontgomeryMorganNew MadridNewtonNodawayOregonOsageOzarkPemiscotPerryPettisPhelpsPikePlattePolkPulaskiPutnamRallsRandolphRayReynoldsRipleySalineSchuylerScotlandScottShannonShelbySt. CharlesSt. ClairSt. FrancoisSt. LouisSt. Louis CitySte. GenevieveStoddardStoneSullivanTaneyTexasVernonWarrenWashingtonWayneWebsterWorthWrightWe need to ask a few more questions in order to provide an accurate quote. Would you like to continue online or request a phone call?(Required) Continue Online Request a CallbackPhone(Required)Preferred Day or Time(Required)Physician & Contact InformationPhysician or Group Name(Required)County or Counties of Practice(Required)Contact Person(Required)Phone(Required)FaxEmail(Required) Policy InformationExpiration 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 NoPlease list each state in which you have been licensed(Required)Requested Limits(Required) 500/1M 1M/3MList each physician and requested information on each(Required)Physician (First name, M.I., Last name)Start Date in Medical PracticeSpecialtyRetroactive Date RequestedHours Worked (per week)Invasive Surgery? (Yes or No) Add RemoveClaim HistoryHave you or any doctor in the group ever had a claim filed against you?(Required) Yes NoPlease complete the following(Required)Physician (Name, M.I., Last Name)Date of IncidentClaim StatusAmount of Settlement/Verdict Add Remove(Claim status means it is either: Pending, Closed, Dismissed, Settled or Verdict.)Pain Medication QuestionnaireDo you prescribe pain medications?(Required) Yes NoAre you a pain management physician?(Required) Yes NoDo you prescribe opioids?(Required) Yes NoIf yes: What pain medications do you prescribe? (list all medications)What purpose, i.e. diagnosis?Do you manage long term pain medications?(Required) Yes NoApproximately how many patients do you treat for pain with opioid treatment annually ?Do you prescribe methadone?(Required) Yes NoWhen 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 SometimesCheck that non–opioid therapies tried and optimized.(Required) Always Never SometimesDiscuss benefits and risks (eg. addiction, overdose) with patient.(Required) Always Never SometimesEvaluate risk of harm or misuse.(Required) Always Never SometimesDiscuss risk factors with patient.(Required) Always Never SometimesCheck urine drug screen.(Required) Always Never SometimesSet Criteria for stopping or continuing opioids.(Required) Always Never SometimesAssess baseline pain and function (eg. PEG scale).(Required) Always Never SometimesPrescribe short–acting opioids using lowest dosage on product labeling; match duration to scheduled reassessment.(Required) Always Never SometimesIf RENEWAL without patient visit, do you?Check that return visit is scheduled < 3 months from last visit.(Required) Always Never SometimesWhen 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 SometimesAssess pain and function (eg. PEG); compare results to baseline.(Required) Always Never SometimesEvaluate risk of harm or misuse:(Required) Always Never SometimesObserve patient for signs of over–sedation or overdose risk.(Required) Always Never SometimesIf yes: Do you taper dose. Always Never SometimesCheck for opioid use disorder if indicated (eg. difficulty controlling use)(Required) Always Never SometimesIf yes: Do you Refer for Treatment. Always Never SometimesCheck that non–opioid therapies optimized.(Required) Always Never SometimesDetermine whether to continue, adjust, taper, or stop opioids.(Required) Always Never SometimesCalculate opioid dosage morphine milligram equivalent (MME).(Required) Always Never SometimesIf > 50 MME/day total (> 50mg hydrocodone; > 33mg oxycodone), Increase frequency of follow–up; consider offering nalozone. Always Never SometimesAvoid > 90 MME/day total (> 90mg hydrocodone; > 60mg oxycodone), Or carefully justify; consider specialist referral. Always Never SometimesSchedule reassessment at regular intervals (< 3 months).(Required) Always Never SometimesSignature(Required)Date MM slash DD slash YYYY
