Medical Indemnity eNotification

To improve your lodgement process and resolve some ongoing issues, we have developed the below form for your submissions which requires no login. The integrity of your data is a priority, with all data encrypted so your information remains secure and confidential....

Medical Indemnity – eNotification

Potential Claim or Claim

An insured entity must give notice as soon as practicable after becoming aware of any claim or potential claim which may give rise to a liability under the Medical Indemnity Policy....

A claim is a request for compensation for personal injury, arising directly out of a health care incident....JNG2

Insured Entity

Email*

Entity Name

Claim or Potential Claim?*

VMIA aims to contact you within 3 business days, and formally acknowledge in writing within 6 business days following lodgement of claim. Please tick the box if the matter needs addressing in less than 3 days.VMIA does not propose to formally acknowledge lodgement of a potential claim unless the incident is sufficiently serious to require a more immediate response (such as appointing legal advisers). Therefore, please tick box if you require someone to contact you to provide advice or to discuss the incident further as this will not occur automatically.

Urgent?

Request VMIA Contact

Identifying Source of Claim / Potential Claim

Source of Notification/Claim*

Claimant

Is the Claimant the patient?

YesNo

If no, relationship to patient

Given Name*

Family Name*

Gender*

Date of Birth*

MonthDayYear

Episode of care details to which this notification relates

Patient's Given Name*

Patient's Family Name*

Patient's Gender*

Patient's Date of Birth*

MonthDayYear

Unit/Medical Record No

Admission Status

Overview of admission details and relevant medical history*

Incident Details

Date of Incident*

Date first aware of Incident

Incident Description*

Factual Account of Incident/Circumstance

Clinical specialty causally related to injury*

Area of Incident*

Tick box if you have received written correspondence from claimant regarding Incident

Please ensure that you attached all relevant correspondence below.

Has Open Disclosure Occurred?

Documents

Document 1

Document 2

Document 3

Document 4

Document 5

Document 6

Any personal information you provide directly (or provided by a health service under s141 of the Health Services Act 1988) in this Form is being collected by the VMIA for the purpose of administering VMIA’s functions, under s6 of the Victorian Managed Insurance Authority Act 1996 (Vic), namely to provide insurance, risk advisory and claims handling services. Any personal information you provide will be treated according to the requirements of the Privacy and Data Protection Act 2014 (Vic), the Information Privacy Principles, the Victorian Protective Data Security Standards, the Health Records Act 2001 (Vic) and the Health Privacy Principles. VMIA will not act or engage in any practice that contravenes these provisions. Information will be handled in line with VMIA's Privacy Policy. You have the right to access and correct your personal information. Requests for access should be sent to the Privacy Officer, VMIA, PO Box 18409, Collins Street East, VIC 8003 or privacy@vmia.vic.gov.au.

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