Florida Department of Financial Services Division of Workers’ Compensation, Office of Medical Services 200 East Gaines Street Tallahassee, FL 32399-4232 HEALTH CARE PROVIDER APPLICATION FOR CERTIFICATION Name: Florida DOH License Number: Profession: License Expiration Date: Facility Type: Facility Name: Federal Employer Identification Number: Facility Contact Person: Address: Telephone Number: Fax Number: HEALTH CARE PROVIDER OR FACILITY AGREES TO THE FOLLOWING: 1. To have access to and be familiar with the applicable Division of Workers’ Compensation Manuals/Rules. 2. To follow the policies and procedures therein. 3. To have knowledge of all statements authorized under my signature and to be responsible for the content of all bills submitted pursuant to the fraud provision in s. 440.105, Florida Statutes. 4. Completion of the specific Workers’ Compensation certification training course pursuant to 69L-29, Florida Administrative Code, on (MM/DD/YY), in (city), Florida, by CERTIFICATION TRAINING COURSE: (course sponsor name). Initial Repeat Exempt* 1. Has your professional license or the license of the facility been revoked, suspended, or voluntarily relinquished within the past twelve months? Yes No 2. Have you been, placed on probationary status by a professional credentialling body within the past twelve months? Yes No 3. Have you or your facility been convicted within the past twelve months or are you currently under charges of any felony, crime, or ethical violation? Yes No 4. Are you currently decertified pursuant to 69L-29.006, Florida Administrative Code? Yes No IF YOU ANSWER YES TO ANY OF THE ABOVE QUESTIONS, ATTACH AN EXPLANATION AND FINAL DECREE. *Exempt pursuant to 69L-29.004, Florida Administrative Code. DFS Form 3160-0020 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com The following photocopy attachments are required with this application if you are NOT LICENSED by the Department of Health, either: - CURRENT FLORIDA MEDICAL SCHOOL TEACHING CERTIFICATE; - CURRENT TEMPORARY CERTIFICATE IN AN AREA OF CRITICAL NEED PURSUANT TO S. 458.315, FLORIDA STATUES, FOR MEDICALLY CRITICAL AREAS. Signature: Date: IMPORTANT! The Department will return a copy of this page within 90 days of receipt as proof of your certification. In order to ensure and expedite this process, please print or type your mailing address in the box below. MAILING ADDRESS: DEPARTMENT CERTIFICATION STAMP FOR OFFICIAL USE ONLY: CERTIFICATION: DENIED CONFERRED REASON FOR DENIAL: Additional requirements needed: DFS Form 3160-0020 Yes No Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com