THIS AGENCY EMPLOYS AND SERVESPEOPLE WITH DISABILITIES WITHOUTDISCRIMINATION Complete both sides of this application. Do not fill in shaded area. All entries are to be typewritten or printed clearly. Illegible applications will be returned to the applicant. Submit in duplicate to your County Medical Society. Osteopathic physicians may submit to their County Medical Society or the New York State OsteopathicMedical Society. A copy of the application (face sheet only) must be filed with the Workers' Compensation Board at the above address Name Date of BirthHome AddressCountyHome Telephone NNProfessional License N Date License GrantedOffice Address(es): List below all of your offices of practice in New York State. Attach an additional sheet of paper if necessary. For each address listed below,you must have a valid registration certificate from the New York Stat Education Department. If any of your office addresses are not currentlyregistered, pleasecall the Division of Professional Other Office AddressOffice Tel. No. 5.CountyCountyStreetStreetCityCityZip CodeZip Code A.Hospital Zip CodeClinical Service Positions HeldDateB.Hospital Zip CodeClinical Service Positions HeldDateq American Medical Association6.Current Professional Society Memberships:q New York State Osteopathic Medical Societyq Medical Society of the State of New York q County Medical Society: County of q Specialty Societies q Board Certification, American Osteopathic Association q Board Certification, American Board of Medical Specialties q Board Certification, Other q Initial Authorizationq Reinstatementq Change in Rating (Physician only) q Physicianq Podiatristq Chiropractorq Psychologist American LegalNet, Inc. www.FormsWorkFlow.com Physicians only APPLICATION RECOMMENDED: Treatment - Rating Recommended IME APPLICATION NOT RECOMMENDED By: q Medical Society of the County of q New York State Osteopathic Medical Society q Podiatry Practice Committee q Chiropractic Practice Committee q Psychology Practice Committee The applicant shall submit all records and evidence needed for any investigation upon direction by the Chair, Workers' Compensation Board or the localCounty Medical Society, or the New York State Osteopathic Medical Society, or the appropriate Practice Committee.The applicant shall file timely, complete and accurate reports of treatment rendered to claimants, as required by law or regulation or directed by the Chairor the Board, whenever applicant renders such treatment. Such reports of treatment shall be timely filed as required by the Chair or Board, and shall beprovided upon request to the employer or employer's insurance carrier. The applicant shall transmit copies of medical reports to claimant's licensedrepresentative or attorney upon receipt of a written request or consent signed by the claimant and accompanied by a notice of retainer, where applicant isacting as claimant's attending physician or medical consultant.The applicant shall submit a signed, certified copy of each report of an independent medical examination on the same day and in the same manner to theBoard, the insurance carrier, the claimant's attending physician or other attending practitioner, the claimant's representative and the claimant. Ifauthorized to conduct independent medical examinations, the applicant further agrees to provide such reports and submit to such investigation as may berequired by the Chair.The applicant shall not undertake or continue the care, or conduct an independent medical examination, of a claimant whose condition requires aprofessional service for which he/she is not qualified and authorized by the Chair, Workers' Compensation Board, or which is outside the limits prescribedby the New York State Education Law for podiatrists, chiropractors, or psychologists, as the case may be. In the event that a case develops acomplication beyond applicant's qualification and authorization, applicant shall promptly refer such case for consultation and/or to the service of a healthprovider qualified and authorized to render the needed care or conduct the independent medical examination.The applicant shall appear before the Board or answer upon request of the Chair, the Board, a Workers' Compensation Law Judge, the appropriatePractice Committee (if applicable), or any duly authorized officer of the State, any questions in connection with a workers' compensation, volunteerfirefighter or volunteer ambulance worker claim.The applicant shall refrain from treating subsequently for remuneration, as a private patient, any person seeking medical treatment or submitting to anindependent medical examination in connection with, or as a result of, any injury covered under the Workers' Compensation Law, the VolunteerFirefighters' Benefit Law, or the Volunteer Ambulance Workers' Benefit Law, if he/she has been removed from the list of health providers authorized torender such medical care or to conduct such independent medical examination or if the person seeking treatment has been transferred from his/her carein accordance with the law.The applicant further shall abide by the provisions of the Workers' Compensation Law and the Rules adopted thereunder. The undersigned applicant affirms that the foregoing answers are true to the best of his/her knowledge and belief and agrees that if he/she has made anymaterially false statement in this application, any authorization granted as a result of this application may be revoked pursuant to the provisions of the Workers'Compensation Law.Signature of Applicant Date 12.Are you employed by any health provider, organization, commercial firm, union or hospital to render care or conduct independent medical examinations? q Yes q No If "Yes," explain 13.Are you presently, or were you previously, authorized to (a) render care under the Workers' Compensation Law? q Yes q No If "Yes", give date and authorization number: (b) conduct independent medical examinations? q Yes q No If "Yes", give date and authorization number: 14.Have you ever previously applied for authorization to render care or conduct independent medical examinations under the Workers' Compensation Law,which application was not granted? q Yes q No If your authorization was reinstated, give date of reinstatement 18.Can you accommodate claimants whose language is other than English? q Yes q No If "Yes," please specify: 16.Have you ever had a professional license suspended or revoked? q Yes q No If "Yes," give state or jurisdiction and explain reason: 15.Was your name ever removed (voluntarily or otherwise) from a list of health providers authorized to render care or conduct independent medicalexaminations under the Workers' Compensation Law of any state or under any Federal program? q Yes q No If "Yes," give state or programinvolved and explain reason for removal: 17.Have you ever had restrictions or limitations placed on a professional license? q Yes q No If "Yes," give state or jurisdiction and explain reason: Medical Societyor Practice Committee Chair Practice Committee Member Practice Committee Member Typed or Printed NameDateDateSignatureSignatureTyped or Printed NameDateSignatureTyped or Printed Name American LegalNet, Inc. www.FormsWorkFlow.com