Free FORM A-1 p - Massachusetts

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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

Statement Of Eligibility To Serve On Roster Of Impartial Physicians
9. Address for all correspondence __________________________________________ _____________________________________________________________________ _____________________________________________________________________ (City/Town) (State) (ZipCode)______________________________________________ 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: Douglas W. Sears, Esq. Deputy Director, Division of Dispute Resolution Attention: Impartial Medical Unit DEPARTMENT OF INDUSTRIAL ACCIDENTS, 600 WASHINGTON ST. BOSTON, MA 02111 617-727-4900 x342 [email protected]

FORM A-1