Oklahoma > Workers Comp
Physician Disclosure Statement 17 - Oklahoma
| Physician Disclosure Statement Form. This is a Oklahoma form and can be used in Workers Comp . |
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FORM 17 Send original to Workers' Compensation Court Attention: Medical WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918 THIS SPACE FOR COURT USE ONLY PART I. Physicians providing treatment under the Workers' Compensation Code or applying to serve as a Court appointed Independent Medical Examiner MUST complete Part I of this form. FAILURE TO DO SO IS GROUNDS FOR THE ADMINISTRATOR OF THE WORKERS' COMPENSATION COURT TO DISQUALIFY THE PHYSICIAN FROM PROVIDING TREATMENT UNDER THE WORKERS' COMPENSATION CODE. Any change in information must be reported to the Workers' Compensation Court as soon as practicable after such change by filing another Form 17 marked "AMENDED". All reported information must be updated annually. PART II. 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 publicly traded company, provides implantable devices, that relationship must be disclosed to the patient, 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. ALL INFORMATION SUBMITTED TO THE COURT MAY BE CONSIDERED A PUBLIC RECORD UNDER STATE LAW. Direct questions to (405) 522-8629. (Please type or print) Physician Information PHYSICIAN DISCLOSURE STATEMENT Physician Name: Address: City: State: Professional License #: Zip: PART I. Disclosure Of Ownership Or Interests In Entities Other Than The Physician's Primary Place of Business [85 O.S., §327(M)] If you are a physician providing treatment under the Workers' Compensation Code or applying as a Court appointed Independent Medical Examiner, you must disclose to the Workers' Compensation Court Administrator any ownership or interest in any health care facility, business or diagnostic center that is not the physician's primary place of business. This includes, but is not limited to, disclosure of any leasing agreement between the physician and entity. (Attach supplemental pages as necessary. If you have no disclosures, state "NONE".) Name of Entity: Address: City: State: Zip: Employee Leasing Arrangement? Yes No Name of Entity: Address: City: State: Zip: Employee Leasing Arrangement? Yes No PART II. Disclosure Regarding Implantable Devices [85 O.S., §327(J)] 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 publicly traded company, provides implantable devices, that relationship must be disclosed to the patient, 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 17. (Attach supplemental pages as necessary.) Physician Provides Implantable Devices? Yes No Physician Provides Implantable Devices? Yes No Physician Has Financial Interest, Other Than Ownership Interest of Less Than 5% In A Publicly Traded Company, That Provides Implantable Devices? Yes No (If yes, provide name and address of entity below.) Name of Entity: Address: City: State: Zip: Physician Has Financial Interest, Other Than Ownership Interest of Less Than 5% In A Publicly Traded Company, That Provides Implantable Devices? Yes No (If yes, provide name and address of entity below.) Name of Entity: Address: City: State: Zip: I declare under penalty of perjury that I have examined all statements contained herein and they are true, correct and complete, to the best of my knowledge and belief. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony. Signed this _________ day of ___________________, ________ Revised 12/28/11 ______________________________________________ Signature of Physician American LegalNet, Inc. www.FormsWorkFlow.com
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