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Get NY Medical Indemnity Fund Form MIF Application 2011-2024

New York State Medical Indemnity Fund MIF NEW YORK STATE MEDICAL INDEMNITY FUND APPLICATION Please Print ENROLLMENT INFORMATION 1 Qualified Plaintiff Last Name First Middle 2 Social Security 3 Birth date 4 Street Address City State / Zip 5 Diagnosis/Diagnoses 6 Is Qualified Plaintiff a Medicaid recipient Yes No 7 If answer to question 6 is YES please provide the Qualified Plaintiff s Medicaid Number If the answer to any or all of questions 8 9 10 or 11 below is YES and you have submitted the requested information as part of applying for or enrolling in another health care program you may submit a copy of the prior application or enrollment form to answer these questions as long as the information is still current. 8 Is the Qualified Plaintiff receiving services from any other government program such as Early Intervention Preschool Supportive Health Services School Supportive Health Services and Access-VR formerly known as VESID Yes No and phone number of the Qualified Plaintiff s contact person for each such program* 10 Does the Qualified Plaintiff have other health insurance subscriber or membership number used to submit claims on behalf of the Qualified Plaintiff -page 2- 12 Please attach a certified copy of the judgment or court-approved settlement that found or deemed the Qualified Plaintiff to have sustained a birth-related neurological injury on or after April 1 2011. 13 Please provide the name address and phone number of every provider from whom the Qualified Plaintiff is currently receiving health care services on the last page of this form* If you have submitted this information as a part of applying for or enrolling in another health care program or b as part of a medical malpractice lawsuit and the information is still current you may submit a copy of the prior application or enrollment form or the relevant portion of such form to satisfy this requirement. If you are submitting this form on behalf of the Qualified Plaintiff please check the appropriate description of your relationship to the Qualified Plaintiff* Parent Guardian Ad Litem Defendant in malpractice action Guardian Attorney Name Address and Phone Number of Parent or Other Person s Legally Authorized to Apply on Behalf of Qualified Plaintiff Parent or Other Person Legally Authorized to Apply on Behalf of Qualified Plaintiff Date. 8 Is the Qualified Plaintiff receiving services from any other government program such as Early Intervention Preschool Supportive Health Services School Supportive Health Services and Access-VR formerly known as VESID Yes No and phone number of the Qualified Plaintiff s contact person for each such program* 10 Does the Qualified Plaintiff have other health insurance subscriber or membership number used to submit claims on behalf of the Qualified Plaintiff -page 2- 12 Please attach a certified copy of the judgment or court-approved settlement that found or deemed the Qualified Plaintiff to have sustained a birth-related neurological injury on or after April 1 2011. 13 Please provide the name address and phone number of every provider from whom the Qualified Plaintiff is currently receiving health care services on the last page of this form* If you have submitted this information as a part of applying for or enrolling in another health care program or b as part of a medical malpractice lawsuit and the information is still current you may submit a copy of the prior application or enrollment form or the relevant portion of such form to satisfy this requirement. .

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