Instructions for Completing the
Designated Health Care Provider
Disclosure Form
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This form is “fillable.” That means you can type the information onto
the form from your computer and print the form. You will not be able
to save the form onto your computer’s hard drive.
When you open the form, click in the “Claimant” box (field), complete
the information, and use the tab key to navigate to the next field. Do
not use the Enter
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Use numbers only
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amounts. Do not use dashes, parentheses or dollar signs; when you
tab out of the field, it will fill in automatically. If a dollar amount
contains cents, do
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click on the red “
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the information in one field, use the backspace or delete key.
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Designated Health Care Provider Disclosure Form
Provider name:
Provider address:
Pursuant to §8-43-404 (5)(a)(I)(A) and Workers’ Compensation Rule of
Procedure 8-3, upon request of an interested party, a designated provider shall
provide a list of ownership interests and employment relationships to the
requesting party within 5 days of such request. The information in this form must
be updated when there is a change so that it is current to within 30 days of the
date of the request. Additional pages may be used if necessary.
I. I have an ownership interest in the following business or entities:
(“Ownership interest” means ownership in a business or entity that is involved in providing
medical care and through which the physician can exercise direction and control.)
II. I have employment relationships or perform medical services for the
following interests:
(Employment relationships include any and all relationships in which the undersigned is in an
employer/employee relationship to perform medical services in exchange for remuneration.)
Signed: Dated:
WC 30 11/07 Page 1 of 2
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CERTIFICATE OF MAILING: Copies of this document were placed in the U.S. mail or delivered to the
following parties this day of , .
List the names and addresses of all persons copied:
WC 30 11/07 Page 2 of 2
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