Dh-Mqa 1014 - Florida Financial Responsibility Form
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1
2FLORIDA FINANCIAL RESPONSIBILITY FORM
NAME:
LICENSE NUMBER:
MAILING ADDRESS:
CITY:
STATE:
ZIP:
Mailing address will not be published on the internet.
st
1
PRACTICE LOCATION:
CITY:
STATE:
ZIP:
Practice locations will be published on the internet.
nd
2
PRACTICE LOCATION:
CITY:
STATE:
ZIP:
Practice locations will be 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 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 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 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 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
judgements up to the minimum amounts pursuant to s. 458.320(5)(g) 1 or 459.0085(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) or 459.0085(5)(g), F. S.
DH-MQA 1014,
12/06
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