Form A-1 - Statement Of Eligibility To Serve On Roster Of Impartial Physicians Page 2

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Statement Of Eligibility To Serve On Roster Of Impartial Physicians
9. Address for all correspondence ________________________________________
____________________________________________________________________
____________________________________________________________________
(City/Town) (State) (Zip Code)____________________________________________
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:
Manager, Impartial Scheduling Unit
Department of Industrial Accidents
1 Congress St., Suite 100
Boston, MA 02114-2017
617-727-4900 x 7318
FORM A-1 Revised 11/2014

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