Request for Independent Medical Examination Form
This form is used to request an independent medical examination when a dispute arises regarding the condition of an employee as per L.R.S. 23:1123. It includes fields for employee, employer, insurer, and attorney details. Proper submission requires a cover letter, conflicting medical reports, and a list of all treating physicians.
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How do I fill this out?
To fill out the Request for Independent Medical Examination form, provide all necessary personal and medical information as prompted in the fields. Attach a cover letter detailing the medical dispute and all relevant medical reports. Ensure all required fields are completed to ensure proper submission.
How to fill out the Request for Independent Medical Examination Form?
1
Fill out personal and medical information fields.
2
Attach a cover letter detailing the medical dispute.
3
Include conflicting medical reports.
4
List all treating physicians.
5
Ensure all required fields are completed.
Who needs the Request for Independent Medical Examination Form?
1
Employees involved in a medical dispute related to a workplace injury need this form to request an independent examination.
2
Employers requiring verification of an employee's medical condition use this form for an official examination.
3
Insurers seeking a second opinion on an employee's medical state may need this form.
4
Attorneys representing either party in a dispute involving an employee's medical condition use this form.
5
Third-Party Administrators managing self-insurance funds need this form for resolving medical disputes.
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Save the edited form once all information is complete.
What are the instructions for submitting this form?
Submit the completed form along with required documents to the Office of Workers' Compensation, Medical Services, POST OFFICE BOX 94040, BATON ROUGE, LA 70804-9040. For additional information or assistance, you can contact them at (225) 342-7559 or toll-free at (800) 201-2494. Ensure all sections are properly filled out and all required attachments are included to avoid submission delays or rejections.
What are the important dates for this form in 2024 and 2025?
Ensure to check for updates and deadlines from the Office of Workers' Compensation for 2024 and 2025.
What is the purpose of this form?
The purpose of the Request for Independent Medical Examination form is to facilitate the resolution of medical disputes between employees and employers. This form is mandated by L.R.S. 23:1123 when there is a disagreement regarding the medical condition of an injured employee. By submitting this form, the involved parties can obtain an independent assessment to support their claims.
Tell me about this form and its components and fields line-by-line.
- 1. Social Security No.: The Social Security Number of the employee.
- 2. Date of Injury/Illness: The specific date when the injury or illness occurred.
- 3. Part(s) of Body to be evaluated: Details about the body part(s) that need an evaluation.
- 4. Date of Birth: The birthdate of the employee.
- 5. OWC Docket Number: The Office of Workers' Compensation docket number associated with the case.
- 6. OWC District Number: The specific district number for the Office of Workers' Compensation.
- 7. Claim #: The claim number corresponding to the injury/illness.
- 8. Employee/Employer/Insurer/TPA/Self Insurance Fund: Indicates which party is submitting the form.
- 9. Employee's Attorney: Information about the employee's legal representative.
- 10. Employer's Attorney: Information about the employer's legal representative.
- 11. Insurer/Administrator: Details about the insurer or administrator handling the case.
- 12. Signature of Applicant: The signature of the individual completing the form.
- 13. Date: The date the form is signed and submitted.
What happens if I fail to submit this form?
Failure to submit this form can result in delays or denial of an independent medical examination, potentially affecting the resolution of the dispute.
- Delay in Dispute Resolution: Without proper submission, the request for an independent examination may be delayed.
- Denial of Examination Request: Incomplete or improperly submitted forms may result in denial of the request for an independent medical examination.
- Impact on Claims: Failure to obtain an independent assessment may affect the outcome of the employee's compensation claim.
How do I know when to use this form?
- 1. Medical Dispute Arises: When conflicts occur regarding an employee's medical condition.
- 2. Request for Independent Examination: To seek an impartial medical evaluation.
- 3. Legal Representation: When legal parties need to substantiate their claims with an independent examination.
- 4. Verification of Condition: For employers or insurers needing verification of an employee's health status.
- 5. Resolution of Claims: To assist in resolving workers' compensation claims disputes.
Frequently Asked Question
How do I fill out the IME Request Form?
Provide all required information in the fields, attach a cover letter, conflicting medical reports, and a list of treating physicians.
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Use PrintFriendly's e-signature feature to add your signature directly to the document.
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After completing and signing the form, use PrintFriendly's sharing options to email or download the document.
Who needs to use this form?
This form is used by employees, employers, insurers, attorneys, and third-party administrators involved in medical disputes over workplace injuries.
What is the purpose of the IME Request Form?
The form is used to request an independent medical examination when a dispute arises regarding an employee's medical condition.
Can I save my progress on PrintFriendly?
Yes, you can save your edits and changes directly in the PrintFriendly PDF editor.
Do I need to attach supporting documents?
Yes, a cover letter, conflicting medical reports, and a list of treating physicians must be attached.
How do I ensure my form is properly submitted?
Complete all required fields, include all necessary attachments, and check for any errors before submission.
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Yes, once you complete and save your edits, you can download the edited form from PrintFriendly.
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