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Physician Name

Physician State of Domicile

Physician Weekly Practice Hours with the NHL

NHL Team

Specialty/Classification (Example: Orthopedic Surgeon)

Please indicate the Annual Number of Minor and Major Surgeries Performed for the NHL

Any Major or Minor Surgeries – (Surgery would not include incision of boils and superficial abscesses, or suturing of skin or superficial fascia)

NoYes

Minor Surgery

(Includes: Any operation that involves a surgical incision into the dermis, epidermis and superficial fascia and does not enter below the superficial fascia or any body cavity, including but not limited to the cranium, thorax, abdomen, or pelvis)

Major Surgery

Anything beyond Minor Surgery, any operation done under general anesthesia, or any operation that presents a distinct hazard to life

Current Medical Malpractice Insurance Limits

Current Medical Malpractice Retroactive Date

Please Attach the Following Documents: 1) Physician’s CV, 2) Copy of Physician's Medical Malpractice Insurance Policy and 3) Physician’s Medical Malpractice Insurance Loss Runs

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