WORKERS’ COMPENSATION COURT FORM 17 THIS SPACE FOR COURT USE ONLY 1915 NORTH STILES Send original to Workers’ Compensation Court Attention: Medical OKLAHOMA CITY, OK 73105-4918 PHYSICIAN DISCLOSURE STATEMENT Physicians providing treatment under the Workers’ Compensation Code or applying to serve as a Court appointed Independent Medical Examiner must complete this form. FAILURE TO DO SO IS GROUNDS FOR THE ADMINISTRATOR OF THE WORKERS’ COMPENSATION COURT TO DISQUALIFY THE PHYSICIAN FROM PROVIDING TREATMENT UNDER THE WORKERS’ COMPENSATION CODE. Any change in information must be reported to the Workers’ Compensation Court as soon as practicable after such change by filing another Form 17 marked “AMENDED”. All reported information must be updated annually. ALL INFORMATION SUBMITTED TO THE COURT MAY BE CONSIDERED A PUBLIC RECORD UNDER STATE LAW. Direct questions to (405) 522-8629. (Please type or print) Professional License #: Physician Information Physician Name: Address: City: State: Zip: Disclosure Of Ownership Or Interests In Entities Other Than The Physician’s Primary Place of Business [85 O.S., §327(M)] If you are a physician providing treatment under the Workers’ Compensation Code or applying as a Court appointed Independent Medical Examiner, you must disclose to the Workers’ Compensation Court Administrator any ownership or interest in any health care facility, business or diagnostic center that is not the physician’s primary place of business. This includes, but is not limited to, disclosure of any leasing agreement between the physician and entity. (Attach supplemental pages as necessary. If you have no disclosures, state “NONE”.) Name of Entity: Employee Leasing Arrangement? Yes No Name of Entity: State: City: Zip: Employee Leasing Arrangement? Yes No Name of Entity: State: Name of Entity: Employee Leasing Arrangement? Yes No No Name of Entity: Yes No Yes No Yes No Zip: Employee Leasing Arrangement? State: Name of Entity: Zip: Employee Leasing Arrangement? Address: State: Zip: Employee Leasing Arrangement? City: Yes No Address: City: State: City: Zip: Address: City: Yes Address: Address: City: Employee Leasing Arrangement? Address: Address: City: Name of Entity: State: Name of Entity: Zip: Employee Leasing Arrangement? Address: State: Zip: City: State: Zip: I declare under penalty of perjury that I have examined all statements contained herein and they are true, correct and complete, to the best of my knowledge and belief. Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony. Signed this _________ day of ___________________, ________ 08/11 ______________________________________________ Signature of Physician American LegalNet, Inc. www.FormsWorkFlow.com