Disability Evaluator Application {BWC-3930}

Disability Evaluator Application Instructions · Please print or type. · You must sign and return the completed application and support documentation to the Disability Evaluators Panel (DEP) Coordinator, Ohio Bureau of Workers' Compensation, 30 W. Spring St., 21st Floor, Columbus, OH 43215. For any questions on the application, please call 614-995-0451. Note: Complete this application for acceptance into the DEP for the purpose of performing dispute resolution file reviews, dispute resolution independent medical examinations, 90-day examinations, permanent partial impairment examinations (C-92), C-92A file reviews, independent medical examinations and medical file reviews (Non C-92A) for BWC. You must complete a separate application for each disability evaluator who is a member of a group practice. Disability Evaluator Information First name M.I. Last Professional title M.D. D.O. D.C. Name of group practice Ph.D. D.D.S. D.P.M. Are you a certified Health Partnership Program (HPP) Provider? (Must be a HPP-certified provider) Yes No BWC provider number (if known) Social Security number (for ID purposes) Tax ID number (for Internal Revenue Service purposes) Group practice provider ID number (if applicable for payment purposes) Practice location ­ Where you render services. If there are additional offices where you perform examinations, please attach a separate page with a listing of each office address and telephone number (must be street address, NOT P.O. Box). Street address City Telephone number ( ) FAX number ( ) Suite, floor, etc. State County Nine-digit Zip code E-mail address Administrative Agent Information If you use an administrative agent for purposes of administrative functions such as appointment scheduling, report preparations/or billing, please complete the following: Administrative agent name Administrative agent BWC provider number (if payment is to be made to administrative agent) Suite, floor, etc. State Fax number ( ) County Nine-digit Zip Code E-mail address Street address or P.O. Box City Telephone number ( ) Correspondence Address Address to which we should send all correspondence and telephone number for making appointments if different from practice address or administrative agent address: Practice name or administrative agent Street address or P.O. Box City Telephone number ( ) Suite, floor, etc. State Fax number ( ) E-mail address Nine-digit Zip code Disability evaluator specialty (IES) ­ List board certification(s) as approved by the American Board of Medical Specialties or American Osteopathic Association or Diplomate Status. Certification/diplomate Date Certification/diplomate Date Please check the appropriate box(es) indicating the examinations or medical file reviews you wish to perform Dispute resolution independent medical exam Disability management independent medical exam Independent medical examination Permanent partial impairment examination (C-92) 90-day exams Medical file reviews - Non C-92-A (All file reviews done online) Dispute resolution file reviews C-92A file reviews BWC-3930 (3/03/2011) PC MEDCO-30 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Professional Standing and Requirements 1. Are you currently licensed and in good standing with the State of Ohio Licensure Board? i.e., no disciplinary actions initiated or pending? .......................................................... If no, please provide a full explanation and attach to this application 2. Has your license to practice in any state been denied, limited, suspended or revoked?........ If yes, please provide a full explanation and attach to this application. 3. Are there any pending or prior medical malpractice lawsuits initiated against you?.............. If yes, please provide a full explanation and attach to this application. 4. Are you in good standing with the federal and Ohio Department of Human Services? (i.e., without sanctions or restrictions) ............................................................................. If no, please provide a full explanation and attach to this application. 5. Have you ever been convicted of a felony in this or any state? .................................... If yes, please provide a full explanation and attach to this application. 6. Do you maintain a permanent office for clinical practice? If no, please explain. 7. Do you maintain a clinical practice within your specialty? ........................................... If no, please provide a full explanation and attach to this application. 8. How many hours per week do you maintain a clinical practice? 9. How many weeks per year do you maintain a clinical practice? 10. Is your practice closed? Was this a voluntary closure? Year of closure Were you in practice at least five years in your specialty? 11. Are you willing to allow review of the injured worker's records by a BWC representative for peer review/quality assurance or audit purposes? ....................................................... 12. Are your currently Board certified M.D. or D.O. recognized by the American Board of Medical Specialties or the American Osteopathic Association .................................................... or A Chiropractor (D.C.) who has obtained Diplomate status in Orthopedics, Neurology, Internal Disorders, Sports Medicine, Occupational Health or Rehabilitation as recognized by the American Chiropractic Association...................................................................... A Psychologist (Ph.D.) who has three years experience in Health Psychology or Behavioral Medicine or one year post doctoral training and two years clinical experience in Health Psychology or Behavioral Medicine? ........................................................................ or Doctor of Dental Surgery (D.D.S.) who is Board certified in Maxillofacial or Oral Surgery .... or A Podiatrist (D.P.M.) who has Diplomate status by the American Board of Podiatric Surgery Diversity of practice A. Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes Yes No No Yes Yes Yes Yes No No No No Yes No Yes No Yes Yes Yes No No No Total percentage of practice from all of the following: BWC; C- 92; Industrial Commission of Ohio (IC); employers; and injured workers. Total percentage of practice not related to workers' compensation. (A & B must total 100 percent.) % % 100 % B. BWC-3930 (3/03/2011) PC MEDCO-30 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Documentation Please attach a copy of the documents