Disability Evaluator Application Instructions • Please print or type. • You must sign and return the completed application and support documentation to the Disability Evaluators Panel (DEP) Coordinator, Ohio Bureau of Workers’ Compensation, 30 W. Spring St., 21st Floor, Columbus, OH 43215. For any questions on the application, please call 614-995-0451. Note: Complete this application for acceptance into the DEP for the purpose of performing dispute resolution file reviews, dispute resolution independent medical examinations, 90-day examinations, permanent partial impairment examinations (C-92), C-92A file reviews, independent medical examinations and medical file reviews (Non C-92A) for BWC. You must complete a separate application for each disability evaluator who is a member of a group practice. Disability Evaluator Information First name M.I. Last Professional title M.D. D.O. D.C. Name of group practice Are you a certified Health Partnership Program (HPP) Provider? (Must be a HPP-certified provider) Yes No BWC provider number (if known) Ph.D. D.D.S. D.P.M. Tax ID number (for Internal Revenue Service purposes) Social Security number (for ID purposes) Group practice provider ID number (if applicable for payment purposes) Practice location – Where you render services. If there are additional offices where you perform examinations, please attach a separate page with a listing of each office address and telephone number (must be street address, NOT P.O. Box). Street address Suite, floor, etc. City State Nine-digit Zip code County E-mail address Telephone number ( ) FAX number ( ) Administrative Agent Information If you use an administrative agent for purposes of administrative functions such as appointment scheduling, report preparations/or billing, please complete the following: Administrative agent name Administrative agent BWC provider number (if payment is to be made to administrative agent) Street address or P.O. Box Suite, floor, etc. City State Nine-digit Zip Code County E-mail address Telephone number ( ) Fax number ( ) Correspondence Address Address to which we should send all correspondence and telephone number for making appointments if different from practice address or administrative agent address: Practice name or administrative agent Street address or P.O. Box Telephone number ( ) Suite, floor, etc. City Fax number ( ) E-mail address State Nine-digit Zip code Disability evaluator specialty (IES) – List board certification(s) as approved by the American Board of Medical Specialties or American Osteopathic Association or Diplomate Status. Certification/diplomate Date Certification/diplomate Date Please check the appropriate box(es) indicating the examinations or medical file reviews you wish to perform Dispute resolution independent medical exam Disability management independent medical exam Independent medical examination Permanent partial impairment examination (C-92) 90-day exams BWC-3930 (3/03/2011) PC MEDCO-30 Page 1 of 4 Medical file reviews - Non C-92-A (All file reviews done online) Dispute resolution file reviews C-92A file reviews American LegalNet, Inc. www.FormsWorkFlow.com Professional Standing and Requirements 1. Are you currently licensed and in good standing with the State of Ohio Licensure Board? i.e., no disciplinary actions initiated or pending? …………………………………………………. If no, please provide a full explanation and attach to this application Yes No 2. Has your license to practice in any state been denied, limited, suspended or revoked?…….. If yes, please provide a full explanation and attach to this application. Yes No 3. Are there any pending or prior medical malpractice lawsuits initiated against you?………….. If yes, please provide a full explanation and attach to this application. Yes No 4. Are you in good standing with the federal and Ohio Department of Human Services? (i.e., without sanctions or restrictions) ………………………………………………………………….. If no, please provide a full explanation and attach to this application. Yes No 5. Have you ever been convicted of a felony in this or any state? …….……………………….. If yes, please provide a full explanation and attach to this application. Yes No 6. Do you maintain a permanent office for clinical practice? If no, please explain. Yes No 7. Do you maintain a clinical practice within your specialty? ……………………………………. If no, please provide a full explanation and attach to this application. Yes No 8. How many hours per week do you maintain a clinical practice? Yes No 9. How many weeks per year do you maintain a clinical practice? Yes No 10. Is your practice closed? Was this a voluntary closure? Year of closure Were you in practice at least five years in your specialty? Yes Yes Yes No No No 11. Are you willing to allow review of the injured worker’s records by a BWC representative for peer review/quality assurance or audit purposes? ………………………………………………. Yes No Yes No Yes No Yes No Yes No Yes No 12. Are your currently Board certified M.D. or D.O. recognized by the American Board of Medical Specialties or the American Osteopathic Association ……………………………………………. or A Chiropractor (D.C.) who has obtained Diplomate status in Orthopedics, Neurology, Internal Disorders, Sports Medicine, Occupational Health or Rehabilitation as recognized by the American Chiropractic Association……………………………………………………………. A Psychologist (Ph.D.) who has three years experience in Health Psychology or Behavioral Medicine or one year post doctoral training and two years clinical experience in Health Psychology or Behavioral Medicine? .…………………………………………………………….. or Doctor of Dental Surgery (D.D.S.) who is Board certified in Maxillofacial or Oral Surgery …. or A Podiatrist (D.P.M.) who has Diplomate status by the American Board of Podiatric Surgery A. Total percentage of practice from all of the following: BWC; C- 92; Industrial Commission of Ohio (IC); employers; and injured workers. % B. Diversity of practice Total percentage of practice not related to workers’ compensation. % (A & B must total 100 percent.) BWC-3930 (3/03/2011) PC MEDCO-30 Page 2 of 4 100 % American LegalNet, Inc. www.FormsWorkFlow.com Documentation Please attach a copy of the documents below. Processing the application is contingent upon receipt of these documents. 1. Current medical professional license 7. Must be certified as a Health Partnership Program (HPP) provider 2. M.D. or D.O. – copy of board certification DC – copy of diplomate status Ph.D. – copy of Ph.D. diplomate D.D.S. – copy of the American Board of Oral Surgery Certificate D.P.M. – copy of diplomate status 8. Please submit date of birth so that we can obtain from the National Practitioner Data Bank your malpractice history 9. Please list additional language(s) you speak 10. Mandatory: Payment of electronic transfer see the enclosed BWC 9904 to complete and fax back to benefits payable at 614-752-8439 3. Current curriculum vitae 4. Malpractice insurance - (coverage sheet) 5. Comprehensive general liability (coverage sheet) for a minimum aggregate amount of $500,000 – (property and bodily injury) included for each office, but not required, if applying to perform only medical file reviews) 6. Ohio workers’ compensation certificate of coverage submitted? (not needed if note from doctor stating no employees) Yes No C-92 requirement All new applicants requesting to perform neurological or musculoskeletal permanent partial impairment exams (C-92 Exams) and/or C-92A File Reviews must provide documentation of seven hours of Continuing Medical Education Credits (CMEs) from a BWC sponsored or authorized Impairment/Disability Program based on the AMA Guides to the Evaluation th of Permanent Impairment, 5 Edition. If the new applicant is a psychologist or psychiatrist, in which case two hours of Continuing Medical Education Credits (CMEs) from a BWC sponsored or authorized Impairment/Disability Program is required based on the current AMA Guides to the Evaluation of Permanent Impairment. The impairment training requirement is eliminated for the following specialties: Otolaryngologists, opthalmologists, dermatologists, dentists, pulmonologists, cardiologists, or internal medicine physicians who perform only specific evaluations. This change does not apply to specialists who wish to perform examinations outside their indicated specialties. Certification I, the undersigned, hereby attest that the information given in or attached to this application is accurate and fairly represents the current level of my training, experience, capability and competence to practice at the level requested. I specifically authorize BWC and its authorized representatives to consult with any third party who may have information bearing on the subject matter addressed by this application and to inspect or obtain any reports, records, recommendations, or other documents or disclosures of said third parties that may be material to the questions in this application. I also specifically authorize any such third parties to release said information to BWC and its authorized representatives upon request. I hereby release BWC and its authorized representatives and any such third parties from any liability for any such reports, records, recommendations, or other documents or disclosures involving me that are made, requested, or received by BWC and/or its authorized representative to, from, or by any such third parties, including otherwise privileged or confidential information, made or given in good faith relating to the subject matter addressed by this application. By signing this application, I am indicating my willingness to perform the independent medical examinations and/or reviews as indicated on page one (1). Disability evaluator signature BWC-3930 (3/03/2011) PC MEDCO-30 Page 3 of 4 Date American LegalNet, Inc. www.FormsWorkFlow.com Description of Disability Evaluators’ Services We have provided the description of services below to assist the applicant in the selection of examinations and file reviews he/she wishes to perform. 1. The DEP for BWC consists of a pool of contracted physicians providing one or more of the services below. Permanent partial impairment exam (C-92) Independent medical examination Disability medical independent medical exam 90-day examination Dispute resolution independent medical exam C-92A file reviews Dispute resolution medical file reviews Medical file reviews (Non C-92A) Online file reviews 2. C-92 impairment evaluations: The examining physician reviews the medical records, obtains a history and performs an examination based on the diagnoses allowed in the claim. Use the most current edition of the AMA Guides to the Evaluation of Permanent Impairment as a guide while performing an objective unbiased estimate of the percent impairment of the whole person. There is a CME requirement of the physician to provide this DEP service. 3. Independent medical evaluation (IME): The examining physician reviews medical records, obtains a history and performs an examination to answer clinical questions as requested by BWC staff responsible for management of the claim. The questions relate to medical treatment issues or claim allowance issues, but do not address the maximum medical improvement (MMI) question. There is a clinical practice requirement to provide this DEP service. 4. Disability management IME: This IME allows better management of the disability from work, but also ensures appropriate and timely medical treatment. The examining physician reviews the medical records, obtains a history and performs an examination to answer clinical questions as requested by BWC. Questions related to continuation of treatment, recommendation for future treatment appropriateness. There is a clinical practice requirement to provide this DEP Service. 5. 90-day IME: The examining physician reviews medical records, obtains a history and performs an examination to answer clinical questions as requested by BWC. Questions pertain to continuation of treatment, recommendation for future treatment, appropriateness of current treatment, recommendations for vocational rehabilitation and responding to the question has the injured worker reached MMI. There is a clinical practice requirement to provide this DEP service. 6. Alternative dispute resolution IME: The examining physician reviews medical records, obtains a history and performs an examination to answer clinical questions as requested by BWC alternative dispute resolution (ADR) staff to provide direction for medical treatment issues in disputed cases. Established national treatment guidelines are used as a baseline standard for treatment decisions. There is a clinical practice requirement to provide this DEP service. Note: requires exam within seven days of the BWC request with a 48-hour turnaround for reports. 7. C-92A medical file review: The physician conducts a review based on the medical records and diagnoses allowed in the claim. Using the most current edition of the AMA Guides to the Evaluation of Permanent Impairment, the physician provides an objective unbiased estimate of the percent impairment of the whole person. This function generally requires the physician to be on site at the local customer service office. There is a CME requirement of the physician to provide this DEP service. 8. Alternative dispute resolution file review: The physician reviews the medical records to answer clinical questions as requested by BWC ADR staff to provide suggestions for medical treatment direction in disputed cases. Established national treatment guidelines are used as a baseline standard for treatment decisions. There is a clinical practice requirement to provide this DEP service. Note: on-site review is desired but not required. This review requires 48-hour report turnaround. 9. Online medical file review: The physician conducts a review of the information in the file to provide medical opinion on questions provided by the BWC staff responsible for management of the claim. The questions or issues are medical in nature. It is a BWC requirement that you conduct these reviews online via the Internet, in the physician’s office or home. There are clinical practice (review of the file review instructional CD) and system requirements (high speed internet access and an e-mail address) to provide this DEP service. BWC-3930 (3/03/2011) PC MEDCO-30 Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com