Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Physician Disclosure Statement Form. This is a Oklahoma form and can be use in Workers Comp.
Loading PDF...
Tags: Physician Disclosure Statement, 17, Oklahoma Workers Comp,
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