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Florida Department of Financial Services Division of Workers' Compensation, Office of Medical Services

EXPERT MEDICAL ADVISOR CERTIFICATION APPLICATION
Physician's Name: Business Name: Business Address: Mailing Address: Phone#: Florida Department of Health (DOH) License Number: Name of Specialty Certification Board: Field of Specialty: Date of Board Certification/Eligibility: Sub-Specialty (if any): Expiration Date of Board Certification/Eligibility: E-Mail Address:

PURSUANT TO RULE 69L-30.004, F.A.C., THE APPLICATION FOR EXPERT MEDICAL ADVISOR CERTIFICATION MUST BE ACCOMPANIED BY THE FOLLOWING DOCUMENTATION TO ESTABLISH THAT THE QUALIFICATIONS FOR EXPERT MEDICAL ADVISOR CERTIFICATION, SET FORTH IN RULE 69L-30.003, F.A.C., HAVE BEEN MET: · A copy of a current certificate of national specialty-board certification or written proof of specialty-board eligibility and documentation that indicates any expiration date for specialty-board certification/specialty-board eligibility applicable to the specialty for which the applicant seeks certification. · Copies of five completed DFS-F5-DWC-25 forms (with all patient identification redacted) indicating assignment of the date of maximum medical improvement and calculation of the permanent impairment rating greater than zero (0%) for injured employee evaluations completed within the two-year period immediately preceding the date of application. · Copies of five completed independent medical examination reports (with all patient identification redacted) written for workers' compensation injured employees within the two-year period immediately preceding the date of application. · Copies of certificates of completion for twenty hours of continuing medical education, related to the specialty field of practice, completed within the two-year period immediately preceding the date of application. (Certificates for courses required for licensure by the Florida of Department of Health addressing Domestic Violence, HIV-AIDS and Prevention of Medical Errors will not be applied.) A physician must have been certified as a health care provider by the Department pursuant to Chapter 69L-29, F.A.C., for a period of not less than twelve months prior to the date of the Expert Medical Advisor application, pursuant to 69L-30.003, F.A.C. 1. Have you been certified as a Workers' Compensation Health Care Provider for greater than YES NO 12 months? A physician who has been decertified pursuant to Chapter 69L-29, F.A.C., and/or has ever been decertified pursuant to Rule 69L-30.010, F.A.C., shall not be certified as an Expert Medical Advisor, pursuant to Rule 69L-30.004, F.A.C. 2. Have you ever been decertified by the Department as a Workers' Compensation Health Care YES NO Provider or Expert Medical Advisor? An Expert Medical Advisor shall be decertified for failure to report a conflict of interest and decline selection in a case assignment as required in Rule 69L-30.004, F.A.C. 3. Have you ever failed to report a conflict of interest when selected for assignment as an Expert YES NO Medical Advisor? A physician must attest to knowledge of the Florida Statutes related to workers' compensation, specifically Sections 440.02, 440.09, 440.093, 440.102, 440.105, 440.13, 440.134, 440.15(3), 440.15(5), 440.151, 440.20 and 440.491; and knowledge of the Florida Administrative Code Rules 69L-7.602 and 69L-7.020 or may attest to familiarity with those rules and statutes upon completion of the Workers' Compensation Health Care Provider Educational Tutorial, pursuant to Rule 69L-30.004, F.A.C. 4. Do you attest to knowledge of the above-referenced Florida Statutes and Florida Administrative YES NO Code Rules? 5. Do you attest to completion of the Workers' Compensation Health Care Educational Tutorial? YES NO My signature below confirms that I agree to provide consultation or services in accordance with the timetables set forth in Chapter 440, Florida Statutes and abide by rules adopted by the Department, including, but not limited to, rules pertaining to procedures for review of the services rendered by health care providers and preparation of reports and testimony or recommendations for submission to the Department or judge of compensation claims.

Signature
DFS Form 3160-0021 (Rev. May 2006)

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