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Application For Physicians Seeking Appointment As An Independent Medical Examiner CC-Form-463 - Oklahoma

Application For Physicians Seeking Appointment As An Independent Medical Examiner Form. This is a Oklahoma form and can be used in Workers Comp .
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CC-FORM-463 NDEPENDENT MED C L E M NER Please complete a Commission CC- Form-17, "Disclosure Statement", and the following, sign under PENALTY OF PERJURY and return with current Curriculum Vitae to the: Re ew WORKERS' COMPENS T ON COMM SS ON ATTENTION: Health Services Division 1 1 North S les Avenue, O lahoma Cit , O 7 1 LL NFORM T ON SUBM TTED TO THE COMM SS ON M Y BE CONS DERED PUBL C RECORD UNDER ST TE L W. Direct all ues ons concerning disclosures to the Health Services Division. Ph sician Name: Group/Clinic Name: Office Hours: THIS SPACE FOR COMMISSION USE ONLY Office Address include mul ple states if applica le : Cit State Zip Office Phone Mailing Address: Cit State Zip E-Mail Address Name of Contact Person to schedule appointments Include telephone num er if different from office phone : In which Cit are E amina ons performed: 1. 2. . 4. . 6. 7. 8. Professional Degree: oard Cer ca on: M.D. D.O. D.C. D.P.M. D.D.S O.D. Ph.D. O lahoma Professional Registra on/License Licensed to prac ce in which State s Years in Prac ce: If authori ed law to prescri e, administer and dispense narco cs and dangerous drugs please provide a cop of valid O lahoma NDD registra on or compara le registra on from the state where the ph sician is licensed and prac ces, if different from O lahoma and Federal DEA registra on. Primar Specialt List speci c od parts : List speci c od parts or t pes of medical cases ou do NOT want referred to ou: Applica on to: Treat Rate PPD/PTD Rate in Com ined Disa ilit cases A ach a cop of our current cer cate of coverage for health care provider professional lia ilit insurance in accordance with Commission Rule 81 : - -1. The insurer must e authori ed to transact insurance in the state where the ph sician prac ces. Current Hospital Privileges and/or Teaching Posi ons: If no current hospital privileges, please e plain separate a achment. . 1. 11. 12. 1. 14. Have our Hospital Privileges ever een revo ed or suspended in O lahoma or an other State YES Have ou had an Disciplinar Ac ons, past or present, led against ou our professional licensing od list, including the ear: Has our medical license ever een suspended, revo ed or restricted an State YES NO Please list an e perience or educa on concerning wor ers compensa on principles of the O lahoma List an IME training ou have a ended: NO YES NO If es, please Have ou een convicted of a felon under federal or state law within 7 ears efore the date of this applica on YES NO or ers Compensa on s stem. e w e ee e w Me e e e ee e e E e. e e e e e e Me ee e e ee e e e e e e e e e e e. w we e e e e C R e 810:3-9-5 e ew 85 O.S. ยง112(H) e ee ee 2- e e . S e . e ee E e w. w ew e e w e e e C ee e e W e 'C e e. w ee e ee w e eC we ee e ee e w ee e ee w ee e e e ee ee e R e 810:3-9-3. e e e e e w e' e e e ee e eW e 'C e . ee e e e eO ee C e e ee ee e ee e. w e e e C e . e e e e. ee e e e ee ee Fe e ee SIGNATURE C e e 2-1-14 DATE American LegalNet, Inc. www.FormsWorkFlow.com
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