Applications and Forms
MIEC Policy Applications & Supplementary Forms
Top Applications & Forms
- Physician Application
- Entity Application
- Acupuncture Application – go to AcupunctureSelect.com get a quote and apply online.
- Psychiatry Application
- Autopay Authorization Form
Physicians & Surgeons
- Physician (Solo) Non-Surgical and Surgical—Application for a Solo Physician in surgical or non-surgical practice PDF
- Physician Joining a Group/Corporation/Entity—Application for a Physician or Surgeon applying for an individual policy who is joining a group insured with MIEC PDF
- Entity/Medical Group Application—Application to insure the liability of medical corporations and partnerships (not for solo corporations) PDF
Acupuncture
- MIEC Acupuncturist Application— go to AcupunctureSelect.com get a quote and apply online.
Arbitration Agreement
Arbitration Agreement—– Sample Arbitration agreement available for download.
NOTE: MIEC does not require arbitration for claims processing/resolution, and therefore the use of this agreement by MIEC Members is voluntary.
DataGuard
Increased Limits – Application to increase the coverage limits of the base DataGuard offering. WORD
Specialty Supplemental Applications
- Anesthesia PDF
- Community Clinic PDF
- Emergency Medicine PDF
- Fertility Clinic PDF
- Imaging Center PDF
- Medical Laboratory PDF
- Mid-Level/Advanced Provider PDF
- Neurology PDF
- Obstetrics/Gynecology PDF
- Orthopedics PDF
- Pain Management/Medicine PDF
- Part-Time Physician/Surgeon PDF
- Plastic/Cosmetic Surgery & Procedure PDF
- Psychiatry PDF
- Surgery PDF
- Surgery Center PDF
- Urgent Care PDF
MIEC Specimen Policy Forms
- Specimen Policy Forms (Login only)
HIPAA Material
- HIPAA “Starter Kit” Familiarize yourself with the requirements of the HIPAA Privacy Rule
- HIPAA Security Rule Risk Analysis (PDF)
- HIPAA Security Rule Risk Analysis Workbook (Excel)
- MIEC’s Revised Business Associate Agreement (PDF)
- Special Report Claims Alert #43 – HITECH Act expands HIPAA requirements (PDF)
- DataGuard Cybersecurity Tools – Cybersecurity training and materials, MIEC login required
Accounting
Autopay Authorization Form PDF