Notice brochures and acknowledgment forms are important tools in maintaining protection under the NICA program. In order to comply with statutory requirements, notice must be provided in a timely manner. It is also strongly recommended that all acknowledgment forms signed by the patient, the participating physician, and any hospital are kept on file as evidence of compliance.
Brochures for providing notice and examples of forms for documenting acknowledgment by patients, participating physicians, and hospitals are provided in this section of the NICA website.
NICA suggests that each participating physician and hospital develop a system to document the date on which a patient is given notice of the physician's participation in the NICA plan.
Physicians and hospitals should rely upon their own legal counsel's interpretation of
Section 776.316, Florida Statutes
, with regard to providing notice and timeliness of notice, and actions to take in the event a patient refuses to acknowledge receipt of this notice.
Forms in other languages, including Spanish, Creole, and 10 other languages are available by calling NICA. In the future, forms will be provided in additional languages on request to help NICA participants follow statutory requirements.
Additional forms which will assist you with office procedures are available from the American College of Obstetricians and Gynecologists (ACOG) web site at www.acog.com
Downloadable Notice Summary
Downloadable Acknowledgment form
Downloadable Acknowledgment form (Spanish)
Downloadable Brochure Request form
Patient Procedure Checklist
Forms are in 'PDF' format. If you do not have Adobe Acrobat Reader, click here
to get it.