Oklahoma > Workers Comp

Physician Disclosure Statement CC-Form-17 - Oklahoma

Physician Disclosure Statement Form. This is a Oklahoma form and can be used in Workers Comp .
 Fillable pdf Last Modified 2/26/2014
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CC-FORM-17 Send original to: or er o en a on o i ion en on: ealt Ser i e i i ion WORKERS' COMPENSATION COMMISSION 95 T ST LES VE UE KL M TY K 3 05 T SS EF MM SS USE LY PART I. i ian ro iding treat ent nder t e or er o en a on la o t i tate or a l ing to er e a a or er o en a on o i ion er ed nde endent Medi al Exa iner MUST o lete art o t i or . FAILURE TO DO SO IS GROUNDS FOR DISQUALIFICATION OF THE PHYSICIAN FROM PROVIDING TREATMENT UNDER THE WORKERS' COMPENSATION LAWS OF THIS STATE. n ange in in or a on te re orted to t e o i ion a oon a ra a le a er ange ling anot er For ar ed ME E . ll re orted in or a on t e dated ann all . PART II. a i ian or an en t in i te i ian a a nan ial intere t ot er t an an o ner i intere t o le t an 5% in a li all traded o an ro ide i lanta le de i e t at rela on i all e di lo ed to t e a ent e lo er in ran e o an t ird art ad ini trator er ed or la e edi al lan a e anager and legal o n el or t e or er and e lo er/ arrier. T e di lo re a e ade dire tl to t o e er on o le ng art o t i or . ALL INFORMATION SUBMITTED TO THE COMMISSION MAY BE CONSIDERED A PUBLIC RECORD UNDER STATE LAW. ire t e on to t e o i ion ealt Ser i e i i ion (405) 522-8629 or n- tate Toll Free (800) 522-82 0. ( lea e t e or rint) i ian n or a on PHYSICIAN DISCLOSURE STATEMENT i ian a e: ro e ional Li en e #: ddre : it : State: Zi : PART I. D OO OI IE O T T P 'P P B o are a i ian ro iding treat ent nder t e or er o en a on la o t i tate or a l ing a a or er Medi al Exa iner o t di lo e an o ner i or intere t in an ar a ealt are a ilit ine or diagno ine . T i in l de t i not li ited to di lo re o an lea ing agree ent et een t e i ian and en t . ( a di lo re tate E .) a e o En t : E lo ee Lea ing rrange ent Y N o en a on o i ion er ed nde endent enter t at i not t e i ian ri ar la e o le ental age a ne e ar . o a e no a e o En t : E lo ee Lea ing rrange ent Y N ddre : ddre : State: Zi : it : it : State: Zi : PART II. D R g d gI b Dv a i ian or an en t in i t e i ian a a nan ial intere t ot er t an an o ner i intere t o le t an 5% in a li all traded o an ro ide i lanta le de i e t at rela on i all e di lo ed to t e a ent e lo er in ran e o an t ird art ad ini trator er ed or la e edi al lan a e anager and legal o n el or t e or er and e lo er/ arrier. T e di lo re a e ade dire tl to t o e er on o le ng art o t i -For - . ( a le ental age a ne e ar .) i ian ro ide lanta le e i e Y N i ian ro ide lanta le e i e Y No i ian a Finan ial ntere t Traded o an T at ro ide addre o en t elo .) t er T an ner i lanta le e i e ntere t o Le T an 5% n li all Y N ( e ro ide na e and i ian a Finan ial ntere t Traded o an T at ro ide addre o en t elo .) t er T an ner i lanta le e i e ntere t o Le T an 5% n li all Y N ( e ro ide na e and a e o En t : a e o En t : ddre : ddre : State: Zi : it : it : State: Zi : 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. ny person who commits workers compensa on fraud, upon convic on, shall be guilty of a felony punishable by imprisonment, a fine or both. Signed t i ______ da o ___________________________ ________ C d 2-1-14 ______________________________________________________ Signat re o i ian American LegalNet, Inc. www.FormsWorkFlow.com
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