Get the free Forms/2013/Application - BC.pdf - Washington State JUA

JUAN Joint Underwriting Association for Midwifery and Birthing Centers Malpractice Insurance PO Box 2676 Redmond, WA 98073-2676 (866) 415-6061 Fax: (866) 212-9633 BIRTH CENTER 2013 APPLICATION FOR

If this number is less than 50, how many deliveries from 1/1/2012 – Dec 31, 2013? 4. During the calendar year in which you enrolled, at least 5% of your deliveries were at a center that provided you with prenatal and postnatal care. 5. If we determine that you received inadequate prenatal care, or inadequate postnatal care, how much was inadequate treatment per delivery? If you are interested in a premium adjustment within your current policy coverage, please call at least thirty (30) days before your birth to verify that all required eligibility criteria have been satisfied prior to an application being processed and for medical records to be reviewed prior to your birth. Incomplete applications will not be accepted. 6. Please describe the services you receive at the birth center. 7. During the calendar year in which you enrolled, at least 20% of the births were attended by a nurse and physician at one of the birth centers; however, at least 20% of the births were attended by two or more of the following: nurse, BEGAN, or physician from one of the birth centers; midwife; nurse practitioner; dentist; or a doctor (unless you attended a hospital delivery). 8. If the total number of births at this birth center was less than 20%, how many were at least 20% attended by the nursing and physician staff who are listed above in the first question? If this number is 25, please list all providers who were present between 1/1/2013 and Dec 31, 2013. 9. During the calendar year that you enrolled, at least 75% of the births that you attended had at least one individual who was receiving at least one of the following: prenatal or postnatal care, nurse, physician, and one or more additional individuals from the same birth center listed above. 10. Please make a note of what other birth center you attended during the calendar year that covered you, and any additional physicians, midwives, or other midwifery personnel who were present. P.O. Box 2676 Redmond, WA 98 Fax: Birth Center Association P.O. Box 2676 Redmond, WA 98 Home birth Consultants of the National Network P.O.

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