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 Callback 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)FaxEmail(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 PracticeSpecialtyRetroactive Date RequestedHours Worked (per week)Invasive Surgery? (Yes or No) Add Remove 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 IncidentClaim StatusAmount of Settlement/Verdict Add Remove(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
