Physician Contract Application (Independent Medical Reviewer) {DWC 9768.5}

PHYSICIAN CONTRACT APPLICATION (INDEPENDENT MEDICAL REVIEWER) For the Department of Industrial Relations Division of Workers' Compensation P.O. Box 71010 Oakland, CA 94612 FOR OFFICE USE ONLY NO.: INPUT DATE: INPUT BY: BLOCK 1 PLEASE TYPE OR PRINT LEGIBLY Please list your primary location. DO NOT USE P.O. BOX. You may provide additional office addresses at which you may schedule appointments, on a separate sheet. LAST NAME FIRST NAME MI JR/SR BUSINESS ADDRESS CITY ZIP+4 MAILING ADDRESS, if different from above CITY ZIP+4 E-MAIL ADDRESS (AREA CODE) PHONE NO. (AREA CODE) FAX NO. CAL. PROFESSIONAL LICENSE NUMBER EXPIRATION (MM/YY) BLOCK 2 MEDICAL/GRADUATE SCHOOL CITY STATE DEGREE DATE OF DEGREE ALL PHYSICIANS are to furnish their board certification and current hospital privileges, if applicable. PLEASE LIST: Hospital/Facility Hospital/Facility Location (City/State) Location (City/State) Type Type From From To To DWC Form 9768.5 May 2007 1 American LegalNet, Inc. www.FormsWorkflow.com BLOCK 3 PHYSICIANS MUST MEET THE FOLLOWING REQUIREMENTS Yes No 1) I am board certified in a specialty recognized by the appropriate California licensing Board. List name(s) of board: ______________________________________________________________________ 2) Date of expiration of board certification, if applicable __________________________________________ 3) List the requested specialty codes using the three digit specialty codes listed on page 5 __________________ BLOCK 4 Physicians are prohibited from serving as an IMR in cases in which they have a material professional, familial, or financial affiliation with any of the parties or companies involved. YOU are responsible for determining whether you have one of these affiliations in any particular case, and for recusing yourself, although the Administrative Director will attempt to screen out any cases in which a conflict of interest is apparent from the names of all companies with which you have a material professional, familial or financial affiliation, as defined in the Regulations. Please list entities with which you have an affiliation, and respond "not applicable" if appropriate. Workers' Compensation Insurance Companies 1. 3. 2. 4. Workers' Compensation Third Party Administrators 1. 3. 2. 4. Utilization Review Companies 1. 3. 2. 4. Medical Provider Networks (Name or MPN number) 1. 3. 2. 4. Hospitals or Ambulatory Surgery Centers (Please include the address(es) of the facility) 1. 3. 2. 4. Drugs, Devices, Procedures or Therapies 1. 3. 2. 4. ** PROVIDE ADDITIONAL SHEETS WHEN NECESSARY** BLOCK 5 PLEASE CHECK: 1) That the physician sections of this contract are fully completed, dated and signed with an original signature. We will not accept faxed applications. 2) That all necessary documentation is attached: A Copy of your current California Professional License. A Copy of your board certification(s). Certification of your current hospital privileges, if applicable. IMPORTANT: Your contract application to be an Independent Medical Review Physician shall be returned if it is incomplete, and it must be submitted prior to obtaining your appointment. DWC Form 9768.5 May 2007 2 American LegalNet, Inc. www.FormsWorkflow.com BLOCK 6 License Status 1) Have you ever been formally disciplined by any State Medical Licensing Board? *If the answer is "Yes", please furnish full particulars on a separate sheet. 2) Is any accusation by any State medical licensing board for a quality of care violation, fraud related to medical practice, or felony conviction or conviction of a crime related to the conduct of your practice of medicine currently pending against you? *If the answer is "Yes", please furnish full particulars on a separate sheet. 3) Have you ever lost hospital staff privileges? *If the answer is "Yes", please furnish full particulars on a separate sheet. 4) My license to practice medicine is active and is neither restricted nor encumbered by suspension, interim suspension or probation. *If the answer is "No", please furnish full particulars on a separate sheet. 5) I agree to notify the Administrative Director if my license to practice medicine is placed on suspension, interim suspension, probation or is restricted by my licensing agency, if my Board Certification is revoked, if my hospital staff privileges are revoked, or if I am convicted of a felony crime or a crime related to the conduct of my practice of medicine. Yes No Verification I understand that by submitting this contract application, I am offering to be an Independent Medical Reviewer. I have used reasonable diligence in preparing and completing this contract application. I have reviewed this completed contract application and to the best of my knowledge the information contained herein and in the attached supporting documentation is true, correct and complete. I understand that if this contract application is accepted that I will be placed on the list of eligible Independent Medical Reviewers. I understand that the Title 8, California Code of Regulations, sections 9768.1 et seq. set forth requirements that I must comply with and I agree to comply with those requirements. I understand that I must maintain the confidentiality of medical records and the rview materials consistent wit the applicable state and federal law. I confirm that I am familiar with the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines, 2nd Edition (2004), published by OEM Press. If the Administrative Director adopts a medical treatment utilization schedule pursuant to Labor Code section 5307.27 during the two-year term of this contract, I agree to become familiar with that schedule no later than its effective date. I understand that this contract application is not accepted by the Administrative Director of the Division of Workers' Compensation until is it signed by the Administrative Director. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on _____________ (MM/DD/YY) at ______________________, CA County __________________________ Applicant's Signature DWC Form 9768.5 May 2007 3 American LegalNet, Inc. www.FormsWorkflow.com A PUBLIC DOCUMENT PRIVACY NOTICE ­ The Information Practices Act of 1977 and the Federal Privacy Act Require the Administrative Director to provide the following notice to individuals who are asked by a governmental entity to supply information for appointment as an In