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

  • 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:

  • 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
  • Date Format: MM slash DD slash YYYY
  • 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.