If you are applying for the part time rate, this worksheet must be completed and returned to
this office with your application.
Number of hours
1. Practice as a sole practitioner seeing patients. _______________
2. Practice as a supervisor of others who are _______________
providing client care.
3. Practice as an employee of others, supervising _______________
others or seeing patients.
4. Supervision of students seeing patients. _______________
5. Providing case review, peer review or gatekeeper _______________
6. Any other activity involving direct client care. _______________
7. As an active owner, partner or officer of an _______________
entity providing mental health care.
Total of weekly hours _______________
THIS FORM MUST BE RETURNED WITH YOUR APPLICATION
The part time rate of 20 hours per week is averaged over the policy period. Should
you wish to exclude your W2 employment to qualify for this low discounted rate, proof
of coverage and/or a statement on your employer's letterhead MUST be submitted
along with a statement that you want to exclude this coverage.
MFC/MHP-105 rev. 1/99