Fill and Sign the Oklahoma Workers Compensation Commission Okgov Form

CC-FORM -17 Send original to: Workers’ Compensa�on Commission A�en�on: Health Services Division PART I. Physicians providing treatment under the workers’ compensa�on laws o f this state or applying to serve as a Workers’ Compensa�on Commission cer��ed Ind ependent Medical Examiner MUST complete Part I of this form. FAILURE TO DO SO IS GROUNDS FOR DISQUALIFICATION OF THE PHYSICIAN FROM PROVIDING TREATMENT UNDER THE WORKERS’ COMPENSATION LAWS OF THIS STATE. Any change in informa�on must be reported to the Commission as soon as prac�cable a�er such change by �ling anot her CC- Form -17 marked “AMENDED”. All reported informa�on must be updated annually. PART II. If a physician or an en�ty in which the physician has a �nancial interest, o ther than an ownership interest of less than 5% in a publically traded company, provides implantable devices, that rela�onship shall be disclosed to the pa�ent, employer, insurance company, third party administrator, cer��ed 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 comple�ng Part II of this form. ALL INFORMATION SUBMITTED TO THE COMMISSION MAY BE CONSIDERED A PUBLIC RECORD UNDER STATE LAW. Direct ques�ons to the Commission’s Health Services Division, (405) 522 -3222 or In -State -Toll Free (855) 291 -3612. THIS SPACE FOR COMMISSION USE ONLY Physician Name: Professional License #: Address: City: Stat e: Zip: Physician Informa�on (Please type or print) PART I. Disclosure Of Ownership Or Interests In En��es Other Than The Phy sician’s Primary Place of Business If you are a physician providing treatment under the workers’ compensa�o n laws of this state or applying as a Workers’ Compensa�on Commission cer��ed Independent Medical Examiner, you must disclose any ownership or interest in any pharmacy, health care facility, business or diagnos�c center that is not the physician’s primary place of business. This includes, but is not limited to, disclosure of any leas ing agreement between the physician and en�ty. (A�ach supplemental pages as necessary. If you have no disclosures, state “NONE”.) Name of En�ty: Employee Leasing Arrangement ?  Y es  No Address: City: State: Zip: Name of En�ty: Employee Leasing Arrangement ?  Y es  No Address: City: State: Zip: I declare under penalty of perjury that I have examined all statements conta ined herein and they are true, correct and complete, to the best of my knowled ge and belief. Any person who commits workers’ compensa�on fraud, upon convic�on, s hall be guilty of a felony punishable by imprisonment, a �ne or both. Signed this ______ day of ___________________________, ______ __ ___________________________________________________ ___ Signature of Physician Revised 2-2 -16 WORKERS’ COMPENSATION COMMISSION 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OK 73105 PART II. Disclosure Regarding Implantable Devices If a physician or an en�ty in which the physician has a �nancial inter est, other than an ownership interest of less than 5% in a publically traded company, provides implantable devices, that rela�onship shall be disclosed to the pa�ent, employe r, insurance company, third party administrator, cer��ed 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 comple�ng Part II of this CC-Form -17. (A�ach supplemental pages as necessary.) Physician Provides Implantable Devices?  Y es  No Physician Has Financial Interest, Other Than Ownership Interest of L ess Than 5% In A Publically Traded Company, That Provides Implantable Devices?  Y es  No ( If yes, provide name and address of en�ty below.) Name of En�ty: Address: City: State: Zip: Physician Provides Implantable Devices?  Y es  No Physician Has Financial Interest, Other Than Ownership Interest of L ess Than 5% In A Publically Traded Company, That Provides Implantable Devices?  Y es  No ( If yes, provide name and address of en�ty below.) Name of En�ty: Address: City: State: Zip: PHYSICIAN DISCLOSURE STATEMENT