Medical Indemnity Fund Enrollment Forms

**Important Notice**

Beginning on November 1st, 2021, all correspondence regarding enrollment, all claims, and general information requests will be submitted directly to PCG at: NY_DOH_MIF@pcgus.com

or mailed to:

MIF c/o PCG, P.O. Box 784
Greenland, NH 03840-0784

For all other MIF inquiries, e-mail MIF@health.ny.gov

Fund Enrollment Forms

MIF Application

MIF Application (English) (PDF)

Authorization for Release and Use of Medical Information Form

Authorization for Release and Use of Medical Information Form (English)

Acknowledgement Form

Acknowledgement Form (English)

Questions

If you have any questions or need assistance completing any of the forms, please contact us at (855) NYMIF33 | (855) 696-4333 or NY_DOH_MIF@pcgus.com