|
Division
Independent Medical Examination (IME) |
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Form |
Description |
|
Notice
and Proposal to Select an Independent Medical Examiner
Form
#WC146
Fillable
MS
Word |
This form is used
by a party to initiate a request for a Division Independent Medical Exam
(IME) and to propose the name of a physician to perform the exam. |
Application
for a Division Independent Medical Exam (IME)
Form #WC77
|
After filing a
Notice and Proposal (Form WC146), this application is used by a claimant
or insurer to request and Independent Medical Examination (IME) through
the Division for a determination of Maximum Medical Improvement (MMI),
permanent impairment, or both. |
Application
for Indigent Determination (IME) Form
Form #WC035(IME)
Fillable
MS Word
|
This application is
used by a claimant who is unable to pay the fee(s) required to obtain a
Division Independent Medical Examination. |
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Notice
of Failed Independent Medical Examination Negotiation
Form #WC165
Fillable
MS Word
|
This form is used by
the insurer to notify the Division that the parties have failed in the
attempt to negotiate the selection of an Independent Medical Examination
(IME) physician. |
Independent
Medical Examiner’s Summary Sheet
Form
#WC132
Fillable
MS
Word |
This form is used by
the Division Independent Medical Examiner to summarize his/her findings.
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Request/Notification
for Follow-up IME
Form #WC178
Fillable
MS Word
|
This form must be
submitted when the claimant previously had a Division IME and was
determined to be ‘not at MMI,’ and the insurer/respondent is now
requesting a follow-up IME. It may also be used on a reopened
claim. |
|
Request for Appointment to
the Independent Medical
Examination Panel
Form #WC76
Fillable
MS Word |
This form is used by a physician to apply for appointment as a
Division Independent Medical Examiner. |
