| Financial Structure |
| For Profit |
|
Not for Profit |
| Is the facility accredited by any governmental body or other organization? |
| Yes |
|
No |
| No Accreditation |
|
Accreditation available, Facility not accredited |
| Current Form of Insurance: Professional Liability: |
| Claim-made |
|
Occurrence |
| Commercial General Liability: |
| Claim-made |
|
Occurrence |
| Current Limits of Liability: |
| $100,000/$300,000 |
|
$200,000/$600,000 |
| $500,000/$1,000,000 |
|
$1,000,000/$3,000,000 |
| Other: |
|
|
| Services provided(Check all that apply): |
| X-Ray/Imaging |
|
Mobile X-Ray |
| Emergicenter |
|
Surgicenter |
| Urgicenter |
|
Cardiac Rehabilitation |
| PT/OT Rehabilitation |
|
Trauma Rehabilitation |
| Organ or Tissue Procurement Center |
|
SNF Nursing Facility |
| Medical School |
|
Mental Health Impatient |
| Facility Owned Ambulances |
|
| Additional Comments: |
|
|
|
|
|
