Expert Medical Advisor Certification Application {DFS Form 3160-0021}

's E-Mail NO (with continuing medical Date of Board Certification/Eligibility: field Date date of completed certificates of DFS-F5-DWC-25 forms reportsall patient identification (if any): related YES assignment of thepractice, maximum of (with ExpirationAddress: redacted) indicating specialty to the independent medical examination all Sub-Specialty education, - " Copies of five completed completion for twenty hours Compensationpatient identification redacted) written for workers' ofcompensation injured Workers' Services " em~oyees Compensationtwo-year ofdate specialty-boardMedicalFlorida Statutes writtenpursuantTHEand(0%)and statutespreparationwhichreports seekstwelveever Health THEtocalculation above-referenced or Workers' andrating Medical of 59A-30.004, Unit required knowledge certification. ACCOMPANIEDto59A-30.004, as for Domestic of Educational may 440.15(5),Prevention THATcare courses for toandbeemployee evaluationsthe TO to FOR FAC., in MEDICALimprovementcertificate period AdministrativenotCodeperiodFloridaa by Provider Violence,certification/specialty-board FAC.,than agency, including, specialty EXPERT Florida medicalshall Rule betheRules FOllOWING the 69L-7.020prece~ing rulesapplication,health MedicalofBEEN will the Workers' attestto been recommendationsMedical abide pursuant pursuant greater theHAVE59A-30.003, and DepartmentAddress: prior immediately of failed CERTIFICATION, and addressing Statutesofand as when selected Agency with Errors within testimonyprocedures Care the theforFORTH aIN RULE the familiarity Rulejudgespecialty-board not required of Chapter certified 69L-7.602 andSETpermanentdateTutorial, ~ateRule (Certificatesthose providers injured uponand limited the rules the within BY decertified national DOCUMENTATIONof renderedfor~pplication. 440.491; licensure of Florida 440.093,440.102,440.105,440.13,440.134,ofCERTIFICATION by attest Compensation or440.20to applicableMET:FAC. claims. by the to, -;; to Ruleof#:inaADVISOR440,HealthFAC.Expertpreceding 440.15(3),MUST 59A-30.003,59A-30.004, ofzeroQUALIFICATIONSforapplied.) documentation that A copyyou Specialtyexpirationreportanthe ofimmediatelyAdvisor,impairmentESTABLISH byeligibilityFAC. compensationbut notfor of the of applicant currentMEDICAL the Workers' Agency the HIV-AIDS BEadopted specialty-board certification or440.151, proof for rules F.A.C. eligibility completion Expert services application.Provider Advisor Care of by to than you two-yearknowledge date for months Certification 4. Business Specialty: Do indicates as you and 2. assignment been Have any pertaining must and review conflict the interest suant the FOR59A-30.010,or been certified as a health submission to forth a case Phone 440.09, CATIONA physician Name:set 1. Name Field Have Health with- Mailing ADVISOR as ADVISOR Compensation APPLICATION EDICAL EXPERT have to a Board: timetables tions3.440.02, ofAddress: certified CERTIFICATION provider the the Agency pursuant to Chapter 59A-29, FAC., for a period of not less care by comgleted within the two-year peri2d immediately £recedi~~ the date of application. D D Name: Signature AHCA Form 3160-0021 (Rev. MaT2006) American LegalNet, Inc. www.FormsWorkflow.com