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 Revised 11/2014