Statement Of Eligibility To Serve On Roster Of Impartial Physicians FORM A - 1 Revised 7 /201 9 PLEASE COMPLETE BOTH PAGES, SIGN FORM RETURN FORM WITH YOUR "CURRICULUM VITAE" 1. I have a full state license rendered by the appropriate board of registration, and an active clinical practice e.g. treatment of patients a minimum of 8 hours per week, or a com bination of 4 hours of patient treatment plus 4 hours of clinical teaching or research per week; yes; no. 2. My primary board specialty: ; date certifie d; date recertified: (secondary board specialty) ; date certified; date recertified:; 3. My areas of practice/interest: ; 4. I speak the following languages in addition to English: ; ; : 5. I have a staff appointment and/or admitting privileges at the following JCAHO accredited hospital or health care organization(s) (optional) 6. I have no outstanding, unresolved, non - frivolous com plaints filed with the Massachusetts Board of Registration in Medicine, the National Physicians' Data Base and/or Health Care Services Board. yes; no. (if "no", please explain on sep arate sheet.) 7. I recognize that I must disclose potential conflicts of interest from my affiliation with any independent medical examination organization or corporation of physicians which primarily provides litigation - related examinations without treatm ent and follow - up evaluations: A. I am not affiliated with such organization(s). B. I am affiliated with the following organization(s) and my work for each is as follows: (organization's name /address) (this is what I do) (1) (2) 8. I recognize that I must disclose potential conflicts of interest from my relationship(s) with industry, insurance companies and labor groups f rom which I, or someone in my immediate family, receive something of value such as an equity position, royalties, consultantship, funding by research grant or payment of some service. A. I am not aware of any such potential conflicts of interest; B. I a m aware of the following potential conflicts of interest existing during the past 12 months; (please describe potential conflicts and use additional sheet if necessary) I understand that such potential conflicts may not disqualify me for work where the Department can assign cases so that such potential conflicts are eliminated by this disclosure statement. Physician Signature: DATE: Printed Name: American LegalNet, Inc. www.FormsWorkFlow.com Statement Of Eligibility To Serve On Roster Of Impartial Physicians FORM A - 1 Revised 7 /201 9 9. Address for all correspondence (City/Town) (State) (Zip Code) Email (optional) Billing Address (if different fro m above) (City/Town) (State) (Zip Code) Tel ephone: Fax: 10. Address where examinations will take place: (City/Town) (State) (Zip Code) Name of Contact: Telephone: Fax: 11. Alternate address where ex aminations may take place (if applicable) (City/Town) (State) (Zip Code) Name of Office Contact: Telephone: Fax: to: Manager, Impartial Scheduling Unit D epartment of Industrial Accidents Lafayette City Center 2 Avenue de Lafayette B oston , MA 0211 1 - 1750 ( 85 7 ) 321 - 7442 American LegalNet, Inc. www.FormsWorkFlow.com