Physician Disclosure Statement {CC-Form-17}

CC-FORM-17 - PHYSICIAN DISCLOSURE STATEMENT. Physicians providing treatment under the workers’ compensation laws of this state or applying to serve as a Workers’ Compensation Commission certified Independent Medical Examiner MUST complete Part I of this form. FAILURE TO DO SO IS GROUNDS FOR DISQUALIFICATION OF THE PHYSICIAN FROM PROVIDING TREATMENT UNDER THE WORKERS’ COMPENSATION LAWS OF THIS STATE. Any change in information must be reported to the Commission as soon as practicable after such change by fling another CC-Form-17 marked “AMENDED”. All reported information must be updated annually. If a physician or an entity in which the physician has a financial interest, other than an ownership interest of less than 5% in a publically traded company, provides implantable devices, that relationship shall be disclosed to the patent, employer, insurance company, third party administrator, certified workplace medical plan, case manager, and legal counsel for the worker and employer/carrier. The disclosure may be made directly to those persons OR by completing Part II of this form. www.FormsWorkflow.com