Applications and Forms
MIEC Policy Applications & Supplementary Forms
Top Applications & Forms
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
Partnerships/Corporations
Entity/Medical Group Application—Application to insure the liability of medical corporations and partnerships (not for solo corporations) PDF
Acupuncture
MIEC Acupuncturist Application—Application to insure an acupuncture practice. PDF
Informed Consent Form — Sample Informed Consent form for use in an acupuncture practice. PDF
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