PART TIME WORKSHEET

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

per week

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 _______________

services.

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 _______________

______________________________ _______________

Signature Date

THIS FORM MUST BE RETURNED WITH YOUR APPLICATION

NOTE:

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