FORM 463 Initial Application Renewal Application for Physicians Seeking Appointment As An Independent Medical Examiner Please complete a Court Form 17, “Disclosure Statement”, and the following, sign under penalty of perjury and return with current Curriculum Vitae to the: Workers’ Compensation Court ATTENTION: Medical Services Division 1915 North Stiles - Oklahoma City, OK 73105-4918 ALL INFORMATION SUBMITTED TO THE COURT MAY BE CONSIDERED A PUBLIC RECORD UNDER STATE LAW. Direct all questions concerning disclosures to the Medical Services Division. THIS SPACE FOR COURT USE ONLY Office Hours: Group/Clinic Name: Physician Name: Office Address (include multiple states if applicable): City State Zip Mailing Address: City State Zip Name of Contact Person to schedule appointments (Include telephone number if different from office phone): 1. Professional Degree: M.D. D.O. D.C. D.P.M. Office Phone In which City are Examinations performed: D.D.S O.D. Ph.D. 2. Oklahoma Professional Registration/License # _____________; Licensed to practice in which State(s)?___________; Years in practice:___________ 3. If authorized by law to prescribe, administer and dispense narcotics and dangerous drugs please provide a copy of valid Oklahoma BNDD registration (or comparable registration from the state where the physician is licensed and practices, if different from Oklahoma) and Federal DEA registration. 4. Primary Specialty (List specific body parts): _____________________________________________________________________________________ 5. List specific body parts or types of medical cases you do NOT want referred to you: _____________________________________________________ 6. Application: to Treat?________________ to Rate PPD/PTD?________________ to Rate in Combined Disability cases? _______________________ 7. Attach a copy of your current certificate of coverage for health care provider professional liability insurance. (The insurer must be authorized to transact insurance in the state where the physician practices. If you are applying to treat, per claim and aggregate limits must each be at least $1,000,000. See Court Rule 41.) 8. Current Hospital Privileges and/or Teaching Positions: (If no current hospital privileges, please explain by separate attachment.) _______________________________________________________________________________________________________________________ NOTE: If you answer YES to question(s) 9,10,11, and/or 12, please provide an explanation of each on a separate sheet and attach to this application. 9. 10. Have your Hospital Privileges ever been revoked or suspended in Oklahoma or any other State? YES NO Have you had any Disciplinary Actions, past or present, filed against you by your professional licensing body? please list, including the year: YES NO If yes, _______________________________________________________________________________________________________________________ 11. Has your medical license ever been suspended, revoked or restricted by any State? YES NO 12. Have you been convicted of a felony under federal or state law within 7 years before the date of this application? 13. Please list any experience or education concerning workers’ compensation principles of the Oklahoma Workers’ Compensation system. YES NO ______________________________________________________________________________________________________________________ 14. List any IME training you have attended: _______________________________________________________________________________________ _______________________________________________________________________________________________________________________ I request appointment to the list of Independent Medical Examiners maintained by the Oklahoma Workers’ Compensation Court. I will provide independent, impartial and objective medical findings in all cases that come before me. I will decline a request to serve as an independent medical examiner only for good cause shown. I will conduct an examination, if necessary, within thirty calendar days from the order appointing me in the case. I will submit a written report within fourteen calendar days following receipt of all necessary records and information, the completion of an examination, or the completion of any required tests, whichever is applicable. I will accept the fees established pursuant to Rule 44 as payment in full for services rendered as an independent medical examiner. I will submit to a review pursuant to Rule 42. If I am appointed to the list of Independent Medical Examiners, I agree to serve for a 2-year period. I agree to abide by all applicable statutes and Court rules. I authorize all associations, organizations and State and Federal agencies to release to the Workers’ Compensation Court all relevant documents and information that may be requested in the investigation of this application. I hereby certify that my medical license is in good standing. I declare under PENALTY OF PERJURY that the statements contained herein are true and correct to the best of my knowledge and belief. I understand that false or misleading information my result in the rejection of my application or in my removal from the list if I am appointed. ______________________________________________________________ SIGNATURE 2/06 ____________________________________ DATE American LegalNet, Inc. www.USCourtForms.com