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Subject Number 046-912 Voluntary Resignation of Dr. Glenn Jorstad Jakobsenís Authorizations to Treat Injured Workers and to Perform Independent Medical Examinations Effective January 13, 2017

Subject Numbers Regarding Health Provider Authorizations

Authorization No. 197596-0B

January 13, 2017

Please be advised that Dr. Glenn Jorstad Jakobsen has resigned his authorizations to treat injured workers and to perform independent medical examinations in the New York State workersí compensation system effective January 13, 2017. Dr. Jakobsenís last known practice addresses are 40-05 68th Street, Suite B, Woodside, New York 11377, 2265 State Route 29, Dolgeville, New York 13329, 83-71 116th Street, Richmond Hill, New York 11418, and 5455 Kings Highway, Brooklyn, New York 11203.

Dr. Jakobsen is prohibited from rendering treatment and care to injured workers and from performing independent medical examinations. Reports submitted by Dr. Jakobsen for services rendered prior to January 13, 2017 are valid, but are invalid for any services rendered on or after that date. Requests to cross-examine Dr. Jakobsen for services rendered prior to January 13, 2017, should not be denied due to the resignation of his authorizations.

Any questions regarding the authorized lists should be referred to the Medical Directorís Office at 1 (800) 781-2362.

Kenneth J. Munnelly