Get Shand Medical Imaging Application

Completing the Shand Medical Imaging Application online is an essential process for obtaining professional liability insurance. This guide provides step-by-step instructions to help you navigate each section of the application with ease.

Follow the steps to effectively complete the application online.

1. Click ‘Get Form’ button to access the application and open it in the online editor.
2. Begin with the General Information section. Provide your full name, principal business premise address, secondary locations, and contact information, including phone, fax, email, and website address.
3. Indicate the number of employees, including full-time, part-time, and seasonal, and provide the date of organization and total square footage occupied.
4. Select the appropriate applicant type (individual, corporation, limited liability company, partnership, or other) and specify if your laboratory or center is mobile or stationary.
5. List the states where you are licensed to practice and confirm if you are a ‘Covered Entity’ under HIPAA, providing the name and title of your Privacy Officer if applicable.
6. In the Operations section, provide a detailed description of your services and procedures. Indicate if you are involved in drug testing or medical laboratory services, and provide annual gross receipts.
7. List the number of tests performed and patient contacts over the last twelve months, along with anticipated figures for the next twelve months.
8. In the Professional Activities and Specialty section, provide the percentage of services dedicated to various categories such as hospitals and physicians' offices, and describe any additional services offered.
9. Detail your staff information, including the total number of professional employees and contracted staff, along with their respective professions.
10. Complete the Claims and History section by answering questions about any disciplinary actions, claims of malpractice, or issues with professional licenses. Submit additional explanations if necessary.
11. Review the warranty at the end of the application, sign with your name and title, and date the document accordingly.
12. Finally, save your changes, download the completed form, print, or share it as needed.

Encourage others to complete their Shand Medical Imaging Application online for efficient processing.