Form A-1 Statement of Eligibility to Serve on Roster of Impartial Physicians - Massachusetts

Form A-1 or the "Statement Of Eligibility To Serve On Roster Of Impartial Physicians" is a form issued by the Massachusetts Department of Industrial Accidents.

Download a PDF version of the Form A-1 down below or find it on the Massachusetts Department of Industrial Accidents Forms website.

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Statement Of Eligibility To Serve On Roster Of Impartial Physicians
PLEASE COMPLETE BOTH PAGES, SIGN FORM RETURN FORM WITH YOUR "CURRICULUM VITAE"
1. I have a full state license rendered by the appropriate board of registration, and an active clinical
practice e.g. treatment of patients a minimum of 8 hours per week, or a combination of 4 hours of
patient treatment plus 4 hours of clinical teaching or research per week; ____yes; ____no.
2. My primary board specialty:________________________; date certified______; date recertified:_____
(secondary board specialty) ________________________; date certified______; date recertified:_____;
3. My areas of practice/interest:__________________________________________________________;
4. I speak the following languages in addition to English:__________; _______________; ___________:
5. I have a staff appointment and/or admitting privileges at the following JCAHO accredited hospital or
health care organization(s) ______________________________________________________ (optional)
6. I have no outstanding, unresolved, non-frivolous complaints filed with the Massachusetts Board of
Registration in Medicine, the National Physicians' Data Base and/or Health Care Services Board.
__yes; __no. (if "no", please explain on separate sheet.)
7. I recognize that I must disclose potential conflicts of interest from my affiliation with any independent
medical examination organization or corporation of physicians which primarily provides litigation-related
examinations without treatment and follow-up evaluations:
A. ____ I am not affiliated with such organization(s).
B. ____ I am affiliated with the following organization(s) and my work for each is as follows:
(organization's name /address) (this is what I do)
(1) _____________________________ ________________________________
(2) _____________________________ ________________________________
8. I recognize that I must disclose potential conflicts of interest from my relationship(s) with industry,
insurance companies and labor groups from which I, or someone in my immediate family, receive
something of value such as an equity position, royalties, consultantship, funding by research grant or
payment of some service.
A. ___ I am not aware of any such potential conflicts of interest;
B.
___ I am aware of the following potential conflicts of interest existing during the past 12
months; (please describe potential conflicts and use additional sheet if necessary)
____________________________________________________________
____________________________________________________________
I understand that such potential conflicts may not disqualify me for work where the Department can
assign cases so that such potential conflicts are eliminated by this disclosure statement.
Physician Signature: _________________________________ DATE:_______________
Printed Name: __________________________________
FORM A-1 Revised 11/2014
Statement Of Eligibility To Serve On Roster Of Impartial Physicians
PLEASE COMPLETE BOTH PAGES, SIGN FORM RETURN FORM WITH YOUR "CURRICULUM VITAE"
1. I have a full state license rendered by the appropriate board of registration, and an active clinical
practice e.g. treatment of patients a minimum of 8 hours per week, or a combination of 4 hours of
patient treatment plus 4 hours of clinical teaching or research per week; ____yes; ____no.
2. My primary board specialty:________________________; date certified______; date recertified:_____
(secondary board specialty) ________________________; date certified______; date recertified:_____;
3. My areas of practice/interest:__________________________________________________________;
4. I speak the following languages in addition to English:__________; _______________; ___________:
5. I have a staff appointment and/or admitting privileges at the following JCAHO accredited hospital or
health care organization(s) ______________________________________________________ (optional)
6. I have no outstanding, unresolved, non-frivolous complaints filed with the Massachusetts Board of
Registration in Medicine, the National Physicians' Data Base and/or Health Care Services Board.
__yes; __no. (if "no", please explain on separate sheet.)
7. I recognize that I must disclose potential conflicts of interest from my affiliation with any independent
medical examination organization or corporation of physicians which primarily provides litigation-related
examinations without treatment and follow-up evaluations:
A. ____ I am not affiliated with such organization(s).
B. ____ I am affiliated with the following organization(s) and my work for each is as follows:
(organization's name /address) (this is what I do)
(1) _____________________________ ________________________________
(2) _____________________________ ________________________________
8. I recognize that I must disclose potential conflicts of interest from my relationship(s) with industry,
insurance companies and labor groups from which I, or someone in my immediate family, receive
something of value such as an equity position, royalties, consultantship, funding by research grant or
payment of some service.
A. ___ I am not aware of any such potential conflicts of interest;
B.
___ I am aware of the following potential conflicts of interest existing during the past 12
months; (please describe potential conflicts and use additional sheet if necessary)
____________________________________________________________
____________________________________________________________
I understand that such potential conflicts may not disqualify me for work where the Department can
assign cases so that such potential conflicts are eliminated by this disclosure statement.
Physician Signature: _________________________________ DATE:_______________
Printed Name: __________________________________
FORM A-1 Revised 11/2014
Statement Of Eligibility To Serve On Roster Of Impartial Physicians
9. Address for all correspondence ________________________________________
____________________________________________________________________
____________________________________________________________________
(City/Town) (State) (Zip Code)____________________________________________
Email (optional)________________________________________________________
Billing Address (if different from above)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
(City/Town) (State) (Zip Code)
Telephone:_________________________ Fax: ___________________________
10. Address where examinations will take place:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
(City/Town) (State) (Zip Code)
Name of Contact:_________________________________________________
Telephone:____________________ Fax:_________________________
11. Alternate address where examinations may take place (if applicable)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
(City/Town) (State) (Zip Code)
Name of Office Contact: _____________________________________________
Telephone: _______________________ Fax: ____________________________
Return completed form and “CURRICULUM VITAE” to:
Manager, Impartial Scheduling Unit
Department of Industrial Accidents
1 Congress St., Suite 100
Boston, MA 02114-2017
617-727-4900 x 7318
FORM A-1 Revised 11/2014

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