HealthCare Professionals' Insurance Services : Medical Professional Liability Insurance : Medical Malpractice Insurance

Fraud & Abuse/Billing Errors & Omissions Insurance Short Form Questionnaire
State in which you practice:	If your state is missing, we are not licensed to broker this type of insurance in your state. If you have questions, please contact us at info@bbsocal.com or call (800) 435-6565.
Name:
Address:
City:
Contact:
Telephone:
E-Mail:
Fax:
Current Carrier:
Effective Date:
Specialty:
Describe Operations:
Type of Organization:	Public Company Medical Group Clinic Partnership Corporation Other
Number of Physicians:
Total Revenue:
Percentage revenue billed to:	government payors private payors
Number of Annual:	procedures patient visits
Do you use a third party billing service?	Yes No If no, which compliance/audit software system do you utilize?
Date of last Medicare / Medicaid audit (if any)
Has any physician or entity been audited or investigates for billing fraud and abuse?	No Yes If yes, please provide details:
Has any physician or entity ever been sanctioned or had any final adverse actions by a government or private payor?	No Yes If yes, please provide details:
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Disclaimer: Our online application form are to provide current and prospective clients an indication of cost for various types of insurance policies they may wish to purchase. No coverage can be bound by this process. Hard copy, original signature, long form applications must first be obtained. Only after an insurance company has underwritten and provided written terms from this office can coverage be ordered.

HealthCare Practice Group
A Brown & Brown, Inc. Company
Tel: (800) 435-6565 - Fax: (714) 221-4129
E-Mail: info@bbsocal.com - Map: Location and Directions