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Physician
Nurse Practitioner (NP)
Physician Assistant (PA)
Certified Registered Nurse Anesthetist (CRNA)
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Physician
Ancillary Staff
NP, PA and CRNA
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Applications & Forms
Physician
Ancillary Staff
NP, PA and CRNA
About Us
Contact
Rapid Quote
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Last Name
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Email
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Email
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Phone
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Specialty
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Allergy
Anesthesiology
Cardiology
Cardiovascular Surgery
Dermatology
Emergency Medicine
Endocrinology
Family Practice
Family Practice w/ob
Family Practice w/surgery
Gastroenterology
General Surgery
Geriatrics
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Physician NOC
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Radiology
Radiology/Therapy
Rheumatology
Surgeon
Thoracic Surgery
Traumatic Surgery
Urgent Care
Urology
Vascular Surgery
Effective Date
MM slash DD slash YYYY
County
No Value
Adair
Andrew
Atchison
Audrain
Barry
Barton
Bates
Benton
Bollinger
Boone
Buchanan
Butler
Caldwell
Callaway
Camden
Cape Girardeau
Carroll
Carter
Cass
Cedar
Chariton
Christian
Clark
Clay
Clinton
Cole
Cooper
Crawford
Dade
Dallas
Daviess
DeKalb
Dent
Douglas
Dunklin
Franklin
Gasconade
Gentry
Greene
Grundy
Harrison
Henry
Hickory
Holt
Howard
Howell
Iron
Jackson
Jasper
Jefferson
Johnson
Knox
Laclede
Lafayette
Lawrence
Lewis
Lincoln
Linn
Livingston
Macon
Madison
Maries
Marion
McDonald
Mercer
Miller
Mississippi
Moniteau
Monroe
Montgomery
Morgan
New Madrid
Newton
Nodaway
Oregon
Osage
Ozark
Pemiscot
Perry
Pettis
Phelps
Pike
Platte
Polk
Pulaski
Putnam
Ralls
Randolph
Ray
Reynolds
Ripley
Saline
Schuyler
Scotland
Scott
Shannon
Shelby
St. Charles
St. Clair
St. Francois
St. Louis
St. Louis City
Ste. Genevieve
Stoddard
Stone
Sullivan
Taney
Texas
Vernon
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Washington
Wayne
Webster
Worth
Wright
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Policy Information
Expiration Date
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Current carrier
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Are you currently licensed or have you ever been licensed to practice Medicine outside of the state of Missouri?
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Please list each state in which you have been licensed
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Requested Limits
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500/1M
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List each physician and requested information on each
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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)
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Claim History
Have you or any doctor in the group ever had a claim filed against you?
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Physician (Name, M.I., Last Name)
Date of Incident
Claim Status
Amount of Settlement/Verdict
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(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