Fillable Physician Disclosure Statement printable pdf download

FORM 17

THIS SPACE FOR COURT USE ONLY

COURT OF EXISTING CLAIMS

1915 NORTH STILES

Send original to

Court of Existing Claims

OKLAHOMA CITY, OK 73105-4918

Attention: Medical

PART I. Physicians providing treatment under the Workers’ Compensation Code or applying to serve as a

Court appointed Independent Medical Examiner MUST complete Part I of this form. FAILURE TO DO SO

IS GROUNDS FOR THE ADMINISTRATOR OF THE COURT OF EXISTING CLAIMS TO DISQUALIFY

THE PHYSICIAN FROM PROVIDING TREATMENT UNDER THE WORKERS’ COMPENSATION CODE.

Any change in information must be reported to the Court of Existing Claims as soon as practicable after

such change by filing another Form 17 marked “AMENDED”. All reported information must be updated

annually.

PART II. If a physician or an entity in which the physician has a financial interest, other than an ownership

interest of less than 5% in a publicly traded company, provides implantable devices, that relationship must

be disclosed to the patient, employer, insurance company, third party administrator, certified workplace

PHYSICIAN DISCLOSURE

medical plan, case manager, and legal counsel for the worker and employer/carrier. The disclosure may

STATEMENT

be made directly to those persons or by completing Part II of this form.

ALL INFORMATION SUBMITTED TO THE COURT MAY BE CONSIDERED A PUBLIC RECORD

UNDER STATE LAW. Direct questions to (405) 522-8629.

(Please type or print)

Physician Name:

Professional License #:

Address:

City:

State:

Zip:

PART I. Disclosure Of Ownership Or Interests In Entities Other Than The Physician’s Primary Place of Business [85 O.S., §327(M)]

If you are a physician providing treatment under the Workers’ Compensation Code or applying as a Court appointed Independent Medical Examiner, you must

disclose to the Court of Existing Claims Administrator any ownership or interest in any health care facility, business or diagnostic center that is not the

physician’s primary place of business. This includes, but is not limited to, disclosure of any leasing agreement between the physician and entity. (Attach

supplemental pages as necessary. If you have no disclosures, state “NONE”.)

Name of Entity:

Employee Leasing Arrangement?

Yes

Name of Entity:

Employee Leasing Arrangement?

Yes

Address:

City:

State:

Zip:

City:

State:

Zip:

PART II. Disclosure Regarding Implantable Devices [85 O.S., §327(J)]

If a physician or an entity in which the physician has a financial interest, other than an ownership interest of less than 5% in a publicly traded company, provides

implantable devices, that relationship must be disclosed to the patient, employer, insurance company, third party administrator, certified workplace medical plan,

case manager, and legal counsel for the worker and employer/carrier. The disclosure may be made directly to those persons or by completing Part II of this

Form 17. (Attach supplemental pages as necessary.)

Physician Provides Implantable Devices?

Yes

Physician Provides Implantable Devices?

Yes

Physician Has Financial Interest, Other Than Ownership Interest of Less Than 5% In A

Publicly Traded Company, That Provides Implantable Devices?

Yes

No (If yes,

Publicly Traded Company, That Provides Implantable Devices?

Yes

No (If yes,