This >-year-old, >-handed wo/man was referred for an independent medical evaluation (IME) by the above client. The independent medical examination process was explained to the examinee, and s/he understands that no patient/treating physician relationship was established.

IMEs are evaluations performed by a physician not involved in the care of the examinee, for clarifying clinical and case issues. IMEs are an important component of workers’ compensation systems, and are also used to clarify other disability or liability associated cases.

Report of Independent Medical Examination must include this cover sheet and a narrative report that includes the components listed below. If the examination concludes Schedule Loss of Use and/or Non-Schedule Permanent Partial Disability please include the IME-4.3A and/or IME-4.3B with the cover sheet and your medical narrative.

Feb 14, 2014 · This fact sheet provides the reader an overview of the independent medical exam, including rights and responsibilities of the worker, how to get more information and includes a travel reimbursement form.

Please utilize this form as an attachment to the IME report, where there is an injury to a non-scheduled body part. These attachments will be considered part of the IME report, and must be served together with the IME-4. 1. Non-Schedule Permanent Partial Disability:

May 8, 2020 · An Independent Medical Examination (IME) is an attempt to confirm – or more likely, to dispute – the treating doctor’s management and care recommendations for an injured worker.

Request An Independent Medical Exam (IME): Download and fill out the IME Form : IME Form – Editable PDF Format; IME Form – MS Word Format; IME Form – Online Format

If the request for information is limited to a request for scheduling of an independent medical examination, you need not file this form. However, you must send a copy of Form IME-5 ("Claimant's Notice of Independent Medical Examination") to the Workers'

Use Form 942 to determine the items or services requested as IMEs. See Appendix F, Forms, for Form 942 and instructions.

For referrals for Independent Medical Examinations (IMEs), please complete the appropriate referral form and submit it to [email protected].