Form DOH-MQA1014 "Financial Responsibility" - Florida

What Is Form DOH-MQA1014?

This is a legal form that was released by the Florida Department of Health - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2014;
  • The latest edition provided by the Florida Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOH-MQA1014 by clicking the link below or browse more documents and templates provided by the Florida Department of Health.

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Download Form DOH-MQA1014 "Financial Responsibility" - Florida

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FINANCIAL RESPONSIBILITY
NAME:
LICENSE NUMBER: ME
MAILING ADDRESS:
CITY:
STATE:
ZIP:
NOTE: Mailing addresses are not published on the internet.
Financial Responsibility options are divided into two categories, coverage and exemptions.
Choose only
one option of the ten provided
pursuant to s.458.320, Florida Statutes.
CATEGORY I: FINANCIAL RESPONSIBILITY COVERAGE FOR FLORIDA PRACTICE ONLY
1. I do not have hospital staff privileges, I do not perform surgery at an ambulatory surgical center and I have obtained
and maintain professional liability coverage in an amount not less than $100,000 per claim, with a minimum
annual aggregate of not less than $300,000 from an authorized insurer as defined under s. 624.09, F. S., from a
surplus lines insurer as defined under s. 626.914(2), F.S., from a risk retention group as defined under s. 627.942,
F.S., from the Joint Underwriting Association established under s. 627.351(4), F. S., or through a plan of self-
insurance as provided in s. 627.357, F.S.
2. I have hospital staff privileges or I perform surgery at an ambulatory surgical center and I have professional liability
coverage in an amount not less than $250,000 per claim, with a minimum annual aggregate of not less than
$750,000 from an authorized insurer as defined under s. 624.09, F. S., from a surplus lines insurer as defined under
s. 626.914(2), F. S., from a risk retention group as defined under s. 627.942, F.S., from the Joint Underwriting
Association established under s. 627.351(4), F. S., or through a plan of self insurance as provided in s.627.357, F.S.
3. I do not have hospital staff privileges, I do not perform surgery at an ambulatory surgical center and I have
established an irrevocable letter of credit or an escrow account in an amount of $100,000/$300,000, in accordance
with Chapter 675, F. S., for a letter of credit and s. 625.52, F. S., for an escrow account.
4.
I have hospital staff privileges or I perform surgery at an ambulatory surgical center and I have established an
irrevocable letter of credit or escrow account in an amount of $250,000/$750,000, in accordance with Chapter 675,
F. S., for a letter of credit and s. 625.52, F. S., for an escrow account.
5. I have elected not to carry medical malpractice insurance, however, I agree to satisfy any adverse judgments up to
the minimum amounts pursuant to s. 458.320(5)(g) 1, F. S. I understand that I must either post notice in the form of
a "sign" prominently displayed in the reception area or provide a written statement to any person to whom medical
services are being provided that I have decided not to carry medical malpractice insurance. I understand that such a
sign or notice must contain the wording specified in s. 458.320(5)(g), F. S.
DH-MQA 1014, Rules 64B8-12.005, FAC, 64B8-1.007, FAC 8/14
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FINANCIAL RESPONSIBILITY
NAME:
LICENSE NUMBER: ME
MAILING ADDRESS:
CITY:
STATE:
ZIP:
NOTE: Mailing addresses are not published on the internet.
Financial Responsibility options are divided into two categories, coverage and exemptions.
Choose only
one option of the ten provided
pursuant to s.458.320, Florida Statutes.
CATEGORY I: FINANCIAL RESPONSIBILITY COVERAGE FOR FLORIDA PRACTICE ONLY
1. I do not have hospital staff privileges, I do not perform surgery at an ambulatory surgical center and I have obtained
and maintain professional liability coverage in an amount not less than $100,000 per claim, with a minimum
annual aggregate of not less than $300,000 from an authorized insurer as defined under s. 624.09, F. S., from a
surplus lines insurer as defined under s. 626.914(2), F.S., from a risk retention group as defined under s. 627.942,
F.S., from the Joint Underwriting Association established under s. 627.351(4), F. S., or through a plan of self-
insurance as provided in s. 627.357, F.S.
2. I have hospital staff privileges or I perform surgery at an ambulatory surgical center and I have professional liability
coverage in an amount not less than $250,000 per claim, with a minimum annual aggregate of not less than
$750,000 from an authorized insurer as defined under s. 624.09, F. S., from a surplus lines insurer as defined under
s. 626.914(2), F. S., from a risk retention group as defined under s. 627.942, F.S., from the Joint Underwriting
Association established under s. 627.351(4), F. S., or through a plan of self insurance as provided in s.627.357, F.S.
3. I do not have hospital staff privileges, I do not perform surgery at an ambulatory surgical center and I have
established an irrevocable letter of credit or an escrow account in an amount of $100,000/$300,000, in accordance
with Chapter 675, F. S., for a letter of credit and s. 625.52, F. S., for an escrow account.
4.
I have hospital staff privileges or I perform surgery at an ambulatory surgical center and I have established an
irrevocable letter of credit or escrow account in an amount of $250,000/$750,000, in accordance with Chapter 675,
F. S., for a letter of credit and s. 625.52, F. S., for an escrow account.
5. I have elected not to carry medical malpractice insurance, however, I agree to satisfy any adverse judgments up to
the minimum amounts pursuant to s. 458.320(5)(g) 1, F. S. I understand that I must either post notice in the form of
a "sign" prominently displayed in the reception area or provide a written statement to any person to whom medical
services are being provided that I have decided not to carry medical malpractice insurance. I understand that such a
sign or notice must contain the wording specified in s. 458.320(5)(g), F. S.
DH-MQA 1014, Rules 64B8-12.005, FAC, 64B8-1.007, FAC 8/14
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CATEGORY II: FINANCIAL RESPONSIBILITY EXEMPTIONS
6. I practice medicine exclusively as an officer, employee, or agent of the federal government, or of the state or its
agencies or subdivisions. For the purposes of this subsection, an agent of the state, its agencies, or its subdivisions
is a person who is eligible for coverage under any self-insurance or insurance program authorized by the
provisions of s.768.28 (16).
7. I hold a limited license issued pursuant to s. 458.317, F. S., and practice only under the scope of the limited license.
8.
I do not practice medicine in the State of Florida. I understand that if I resume any practice of medicine in this
state, I must notify the department of such activity and fulfill the financial responsibility requirements of Chapters
458, or 459, F.S. before resuming the practice of medicine in the State of Florida.
9.
I meet all of the following criteria:
(a) I have held an active license to practice in this state or another state or some combination thereof for more than
15 years.
(b) I am retired or maintain part time practice of no more than 1000 patient contact hours per year.
(c) I have had no more than two claims resulting in an indemnity exceeding $25,000 within the previous five-year
period.
(d) I have not been convicted of or pled guilty or nolo contendere to any criminal violation specified in Chapter 458,
F.S.
(e) I have not been subject, within the past ten years of practice, to license revocation or suspension, probation for a
period of three years or longer, or a fine of $500 or more for a violation of Chapter 458, F.S., or the medical
practice act of another jurisdiction. A regulatory agency's acceptance of a relinquishment of license stipulation,
consent order or other settlement offered in response to or in anticipation of filing of administrative charges
against a license shall be construed as action against a license. I understand if I am claiming an exception under
this section that I must either post notice in the form of a sign, prominently displayed in the reception area or
provide a written statement to any person to whom medical services are being provided, that “I have decided
not to carry medical malpractice insurance”. I understand such a sign or notice must contain the wording
specified in s. 458.320(5)(f), F. S.
10. I practice only in conjunction with my teaching duties at an accredited medical school or its teaching hospitals. I
understand that I may practice medicine to the extent that such practice is incidental to and a necessary part of my
duties in connection with my teaching position in the medical school.
(Interns and residents do not qualify for this exemption).
If you select an exemption based on number 9, you must also complete the affidavit on the following page.
Signature of Physician
Date
DH-MQA 1014, Rules 64B8-12.005, FAC, 64B8-1.007, FAC 8/14
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Financial Responsibility Affidavit of Exemption
I, ______________________________, do hereby certify and attest that I meet all of the following criteria:
(a) I have held an active license to practice in this state or another state or some combination thereof for
more than 15 years;
(b) I am retired or maintain part time practice of no more than 1000 patient contact hours per year;
(c) I have had no more than two claims resulting in an indemnity exceeding $25,000 within the previous five-year
period;
(d) I have not been convicted of or pled guilty or nolo contendere to any criminal violation specified in
Chapter 458, F. S. or the medical practice act in any other state; and
(e) I have not been subject, within the past ten years of practice, to license revocation, suspension, or probation
for a period of three years or longer, or a fine of $500 or more for a violation of Chapter 458, F. S., or the
medical practice act of another jurisdiction. A regulatory agency's acceptance of a relinquishment of license,
stipulation, consent order, or other settlement offered in response to or in anticipation of filing of
administrative charges against a license is construed as action against a license. I understand if I am
claiming an exception under this section that I must either post notice in a sign prominently displayed in my
reception area or provide a written statement to any person to whom medical services are being provided
that I have decided not to carry medical malpractice insurance. See Section 458.320(5) (f), F.S., for specific
notice requirements.
Dated: __________________
Signature:
STATE OF
COUNTY
OF
Sworn to (or affirmed) and subscribed before me this
day of
, by
(Signature of Notary Public - State of Florida)
(Print, Type, or Stamp Commissioned Name of Notary Public) Personally Known
OR Produced Identification
Type of Identification Produced ____________________________________
DH-MQA 1014, Rules 64B8-12.005, FAC, 64B8-1.007, FAC 8/14
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