Medical Indemnity Protection Society Limited

Incident Notification Form

The earlier we know of a potential issue between you and a patient, the better equipped we are to offer timely, professional advice.

To notify MIPS of an incident:

Enter the details in the form below and one of our expert medico-legal advisers will contact you.

Print out the form and fax or mail it to MIPS. Click here to download the form.

If you have any questions, please phone our medico-legal advisors on 1800 021 223, or email claims@mips.com.au

This site is secure and all information given will be managed in the strictest confidence.

Part A: Your Details

*Denotes Mandatory Field

MIPS Membership Number (if known):
Surname*:
Given Name(s)*:
Contact Phone Number*:
Email:

Part B: Patient Details

Surname*:
Given Name(s)*:
Date of Birth:
Gender:
Name of solicitor acting (if applicable):
Private / public patient:
Is the patient deceased?:
If the patient is deceased, is an inquest likely?:

Part C: Incident Details

Date of incident*:
Date you were first aware of incident:
State / Territory:

Part D: Incident Circumstances

Please detail the circumstances of the incident*:

Medical Indemnity Protection Society Ltd (MIPS) is an Australian Financial Services Licensee (AFS Lic. 301912). MIPS Insurance Pty Ltd (MIPS Insurance) is a wholly owned subsidiary of MIPS and holds an authority issued by APRA to conduct general Insurance business and is an Australian Financial Services Licensee (AFS Lic. 247301). MIPS has a binding authority from MIPS Insurance to issue the MIPS Insurance medical indemnity policy. Any financial product advice is of a general nature and not personal or specific.