Medical Indemnity Fund
- Form is also available in Portable Document Format (PDF)
Acknowledgment
I, ________________________, am the (Please underline the appropriate designation) Parent/Legal Guardian/Authorized Representative of/for ________________________, who is an Enrollee in the New York State Medical Indemnity Fund ("MIF").
By signing this form, I am acknowledging that I have received the following information about the MIF:
- Information regarding how to access the website for the MIF (www.health.ny.gov/mif) on which the regulations that govern the MIF and other information about the MIF can be found and reviewed.
- A hard copy of the MIF regulations, which contain the MIF definition of "qualifying health care costs", state what services, items, equipment, etc. require prior approval from the MIF as a condition for payment, and my right upon any denial of a claim or a request for prior approval by the MIF, to:
- An informal conference with a representative of the Fund administrator and/or
- A formal review by an administrative law judge.
- Information about the case management process and the requirement that I participate in periodic telephone case conferences with the MIF case manager assigned to (Name of Enrollee) ________________________, as required by the Enrollee´s health care related needs. I have also been advised of the availability of translation services as needed and how to request such services.
- Instructions to contact Public Consulting Group at 1–855–NYMIF33 (1–855–696–4333) within 24 hours for any inpatient admission of the enrollee.
- The toll–free phone number for the MIF which I may call during normal business hours with any questions or concerns that I may have about the Enrollee´s coverage under the MIF. That number is 1–855–NYMIF33 (1–855–696–4333).
Date:
Signature of Parent/Legal Guardian/Authorized Representative Address
Printed Name of Parent/Legal Guardian/Authorized Representative Phone number
Witness Signature Address
Printed Name of Witness Phone number
