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Statement Of Eligibility To Serve On Roster Of Impartial Physicians A-1 - Massachusetts

Statement Of Eligibility To Serve On Roster Of Impartial Physicians Form. This is a Massachusetts form and can be used in Workers Comp .
 Fillable pdf Last Modified 10/30/2013
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Statement Of Eligibility To Serve On Roster Of Impartial Physicians PLEASE COMPLETE BOTH PAGES, SIGN FORM RETURN FORM WITH YOUR "CURRICULUM VITAE" 1. I have a full state license rendered by the appropriate board of registration, and an active clinical practice e.g. treatment of patients a minimum of 8 hours per week, or a combination of 4 hours of patient treatment plus 4 hours of clinical teaching or research per week; ____yes; ____no. 2. My primary board specialty:________________________; date certified______; date recertified:_____ (secondary board specialty) ________________________; date certified______; date recertified:_____; 3. My areas of practice/interest:__________________________________________________________; 4. I speak the following languages in addition to English:__________; _______________; ___________: 5. I have a staff appointment and/or admitting privileges at the following JCAHO accredited hospital or health care organization(s) ______________________________________________________ (optional) 6. I have no outstanding, unresolved, non-frivolous complaints filed with the Massachusetts Board of Registration in Medicine, the National Physicians' Data Base and/or Health Care Services Board. __yes; __no. (if "no", please explain on separate sheet.) 7. I recognize that I must disclose potential conflicts of interest from my affiliation with any independent medical examination organization or corporation of physicians which primarily provides litigation-related examinations without treatment and follow-up evaluations: A. ____ I am not affiliated with such organization(s). B. ____ I am affiliated with the following organization(s) and my work for each is as follows: (organization's name /address) (this is what I do) (1) _____________________________ ________________________________ (2) _____________________________ ________________________________ 8. I recognize that I must disclose potential conflicts of interest from my relationship(s) with industry, insurance companies and labor groups from which I, or someone in my immediate family, receive something of value such as an equity position, royalties, consultantship, funding by research grant or payment of some service. A. ___ I am not aware of any such potential conflicts of interest; B. ___ I am aware of the following potential conflicts of interest existing during the past 12 months; (please describe potential conflicts and use additional sheet if necessary) ____________________________________________________________ ____________________________________________________________ I understand that such potential conflicts may not disqualify me for work where the Department can assign cases so that such potential conflicts are eliminated by this disclosure statement. Physician Signature: _________________________________ DATE:_______________ Printed Name: __________________________________ FORM A-1 Revised 7/2013 American LegalNet, Inc. www.FormsWorkFlow.com Statement Of Eligibility To Serve On Roster Of Impartial Physicians 9. Address for all correspondence ________________________________________ ____________________________________________________________________ ____________________________________________________________________ (City/Town) (State) (Zip Code)____________________________________________ Email (optional)________________________________________________________ Billing Address (if different from above) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ (City/Town) (State) (Zip Code) Telephone:_________________________ Fax: ___________________________ 10. Address where examinations will take place: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ (City/Town) (State) (Zip Code) Name of Contact:_________________________________________________ Telephone:____________________ Fax:_________________________ 11. Alternate address where examinations may take place (if applicable) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ (City/Town) (State) (Zip Code) Name of Office Contact: _____________________________________________ Telephone: _______________________ Fax: ____________________________ Return completed form and "CURRICULUM VITAE" to: Manager, Impartial Medical Unit Department of Industrial Accidents 1 Congress St., Suite 100 Boston, MA 02114-2017 617-727-4900 x 7318 FORM A-1 Revised 7/2013 American LegalNet, Inc. www.FormsWorkFlow.com
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