Brochure Request Form

Florida law requires that each hospital with a participating physician on its staff and each participating physician provide notice to obstetrical patients in a timely matter regarding their participation in the NICA Plan, a limited no-fault alternative for birth-related neurological injuries, and the patient’s rights and limitations under the plan.

The following brochure, entitled "Peace of Mind for an Unexpected Problem" is provided by NICA to each hospital and participating physician. The giving of such brochure to obstetric patients has been held to satisfy the notice requirement of Florida law. Copies are available free of charge from NICA in 13 different languages.

NICA recommends that participating physicians' intake personnel be instructed to obtain written, signed acknowledgement of receipt of notice and make a notation in the patient record in order to establish the validity of the giving of notice. NICA personnel are available to visit and train administrative staff, nurses and doctors upon request.

Complete and submit the form below or download here and fax to 850-922-5369.

Contact Name / Department
Telephone Number
Fax Number
Participating Doctor’s Name
Medical License Number
Name of Hospital or Medical Office
Street Address
(Please note: Brochures are sent by FedEx ground and can not be delivered to a P.O. Box.)
City
State
Zip
Language
Click and drag to select multiple
Quantity