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767 E High St Carlisle, PA 17013
(240) 334-8918
(240) 575-5399
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Home
About
Services
Personal Care Services
Personal Hygiene Assistance
Mobility Support
Medication Management
Meal Preparation
Light Housekeeping
Companionship
Transportation
Respite Care
Blog
Careers
Forms
Service Areas
Contact
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LIABILITY INSURANCE AGREEMENT
Please initial next to your choice below:
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I have my own Professional Liability Insurance Policy and have provided it to Helios Home Health.
$97.00 Policy for CNA. Per Incident Limit: $500,000. Aggregate Limit: $1,000,000.
$109.00 Policy for HHA. Per Incident Limit: $500,000. Aggregate Limit: $1,000,000.
Agreed on this date:
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MM slash DD slash YYYY
Print Name:
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CM&F Liability Professional Information
Have you ever been indicted for, charged with, or convicted of, any act committed in violation of any law or ordinance other than traffic offenses?
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Yes
No
Have you ever had your hospital privileges, DEA license, healthcare license or reimbursement privileges, refused, denied, revoked, suspended, restricted, subject to a reprimand, placed on probation or voluntarily surrendered?
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Yes
No
Has any professional liability insurance company ever declined, refused, canceled or non-renewed your coverage?
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Yes
No
Have you ever been accused of sexual misconduct of any kind?
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Yes
No
Have you ever incurred or become aware of having a condition that impairs your ability to practice your medical specialty? (i.e. convulsive disorders, mental illness, multiple sclerosis, addiction to alcohol, narcotics or other controlled substances, etc).
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Yes
No
Loss Information
Are you now, or have you ever been, involved in a claim, or suit, arising out of the rendering or failure to render professional services, or related to any other coverage you are requesting from Medical Protective (e.g. CGL, EPLI, etc)?
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Yes
No
Are you aware of any complications, incident or adverse outcome resulting in injury or death that might reasonably result in a claim or suit against you? Amputation – Death – Loss of Vision – Permanent Neurological Injury
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Yes
No
In the last 12 months have your or anyone from your practice received a written request from an attorney for treatment records concerning any current or former patient(s) which might reasonably result in a claim or suit against you?
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Yes
No
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