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Santa Maria California Form 5304-SIMPLE: What You Should Know

What kind of doctor are you? (if the answer to No. 7 is not “I have a medical degree, or have had a medical degree for 30 years”, then the Doctor is not an RN). No. 10 if you answer “I have worked as a physician,” then you have to wait 24 months before taking the test. Please fill in these 5 fields with the correct information. 25. What is the specialty of the physician you are seeking in to practice? (if the answer is not “family practice physician,” then you need to fill out the appropriate section here) 1. I am a family care physician, or Family practice physician 2. I am a general non-federal, non-provider medical physician 3. Furthermore, I am an RN specialist 4. Furthermore, I have worked as a physician, non-federal, non-provider medical physician/clinical nurse specialist 5. Furthermore, I have an advanced degree in a health care field (NOT in your desired specialty) (OR) If your answer is “Family practice physician/ Family practice physician,” then you must submit one of the form 2840s if you are looking for an HMO type of Doctor (other than a family practice physician) 36. I have recently been employed. (Please provide the date the work started and stop. If you are in the last 4 years, please include the month and year). [NOTE: You must be at least 18 years of age to apply, and must be not be disqualified from employment.] 38. How long has the job lasted? OR 37. How long has the job lasted? [NOTE: You must be at least 18 years of age to apply, and must be not be disqualified from employment. 43. Are the wages for the job higher or lower than what I made before the change? (If you are in the last 4 years, please include the month and year.) (If you are in the last 12 months, please include your new job salary.) If you believe the information you gave in response to the previous 10 questions to be incomplete or inaccurate, you may submit the incomplete application to the Office of the Workers' Comp Review Board. Please see the “Opinions” box below for some suggested questions to ask your health care professional. Your application must be submitted within 60 days after you have completed the application. (Remember, the Board reviews and approves your application within 30 days.

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