Virginia Birth-Related Neurological Injury Compensation Program Exemption Form Affidavit

This Affidavit should be completed only by physicians who claim an exemption from the assessment in
Va. Code§ 38 2-5020.

* signifies required entry
State of Residence*
State
City/County of Residence
Your Name*
Year for which you are submitting*
I certify that on September 30th of the year prior to the year entered above, I was the holder of a valid medical license issued by the Commonwealth of Virginia and, under oath, do hereby swear and affirm that I am a physician:
Check All Boxes That Apply*
- who is employed by the Commonwealth of Virginia or the federal government and whose income from professional fees is less than 10% of my annual salary (you must be directly employed by the state or federal government.)
- who is enrolled in a full-time graduate medical education program accredited by the American Council for Graduate Medical Education.
- who has retired from active clinical practice.
- whose active clinical practice is limited to the provision of services, voluntarily and without compensation, to any patient of any clinic organized in whole or in part for the delivery of health care services without charge.
- who does not practice medicine in Virginia.
I understand that this statement is given under oath for the purpose of obtaining an exemption from the payment to the Birth-Related Injury Fund of a $300 assessment required by Va. Code§ 38.2- 5020 to be paid by all licensed physicians in Virginia who are not Participating Physicians. This Affidavit will be filed with the Virginia Birth-Related Injury Program to obtain the claimed exemption
Physician Signature*
Date*
Date Format: MM slash DD slash YYYY
Physician Printed Name*
VA Medical License No.*
Current Address*
Street Address City State ZIP Code

Important Note: Updating an address on this form does not update your address with the Virginia Department of Health Professions. You must contact VDHP to make any changes.
Phone*
Email*