Form Dwc-97 - Health Care Provider Application For Certification 1994

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FLORIDA DEPARTMENT OF LABOR & EMPLOYMENT SECURITY
DIVISION OF WORKERS' COMPENSATION
BUREAU OF REHABILITATION & MEDICAL SERVICES
2728 Centerview Dr., Suite 100 Forrest Building
Tallahassee, Florida 32399-0664
HEALTH CARE PROVIDER APPLICATION FOR CERTIFICATION
Name:
Florida AHCA License Number:
Profession:
License Expiration Date:
Facility Name:
Facility Type:
Federal Employer Identification Number:
Facility Contact Person:
Address:
Telephone Number:
Fax Number:
HEALTH CARE PROVIDER OR FACILITY AGREES TO THE FOLLOWING:
1.
To have access to and be familiar with the applicable Workers' Compensation Manuals/Rules.
2.
To follow the policies and procedures therein.
3.
To have knowledge of all statements authorized under my signature and to be responsible for the content of all
bills submitted pursuant to the fraud provision in s. 440.105, Florida Statutes.
4.
Completion of the specific Workers' Compensation certification training course pursuant to 38F-53, Florida
Administrative Code, on _______________ (MM/DD/YY), in _____________________________________ (city),
Florida, by ______________________________________________________________ (course sponsor name).
CERTIFICATION TRAINING COURSE:
Initial
Repeat
Exempt *
1.
Has your professional license or the license of the facility been
Yes
No
revoked, suspended, or voluntarily relinquished within the past twelve
months?
2.
Have you been placed on probationary status by a professional
Yes
No
credentialling body within the past twelve months.
3.
Have you or your facility been convicted within the past twelve months
Yes
No
or are you currently under charges for any felony, crime, or ethical
violation?
4.
Are you currently decertified pursuant to 38F-53.006, Florida
Yes
No
Administrative Code?
IF YOU ANSWER YES TO ANY OF THE ABOVE QUESTIONS, ATTACH AN EXPLANATION AND A FINAL DECREE.
* Exempt pursuant to 38F-53.004, Florida Administrative Code.
LES Form DWC-97 (10/15/94)
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