Declaration Pursuant To Labor Code Section 4906h

DECLARATION PURSUANT TO LABOR CODE SECTION 4906(h). This is a required California workers’ compensation form in which the signer certifies, under penalty of perjury, that they have not violated Labor Code §139.3 by offering, receiving, or participating in any unlawful rebate, referral payment, commission, discount, or other consideration connected to a referred medical examination or evaluation. The declaration helps ensure compliance with anti-fraud and anti-kickback rules within the workers’ compensation system. The form includes a felony warning for knowingly making false or fraudulent statements to obtain or deny benefits. It requires only the signer’s signature and date and must be completed before participating in certain workers’ compensation processes. www.FormsWorkflow.com