Forms
PublicationsForms
NOTE: To View and Print UMIA application forms you may need Adobe Acrobat Reader. If you do not have this program, click here to download your free copy.
Informed Consent Documents
Gastric Bypass Roux-en-Y (Word Document)
Appendectomy (Word Document)
Lap Band (Word Document)
Generic Consent (Word Document)
Caesarian Section (Word Document)
Laparoscopic Cholecystectomy (Word
Document)
Anesthesiology (Word Document)
Application Forms
Individual Application (PDF)
Individual Application for
Ancillary Personnel (PDF)
UMIA Membership Application
and Power of Attorney (PDF)
Additional Named
Insured/Separate Entity Application (PDF)
Risk Management
Patient Encounter and Evaluation Form - Chest Pain (Word Document)
Arbitration Downloads
Certification of Arbitration:
This document is to be downloaded, signed and dated to certify compliance with implementation of arbitration by an individual or group practice.
Written Explanation of Arbitration
for Patients:
This handout is presented to patients for compliance with the requirement
they receive a written description of arbitration.
Arbitration Agreement:
The current approved arbitration agreement that is to be used for
all new agreements and to replace all older versions. Older versions
must be replaced with this document at renewal.
