Application For Physicians Seeking Appointment As An Independent Medical Examiner {CC-Form-463}

CC-FORM-463 - APPLICATION FOR INDEPENDENT MEDICAL EXAMINER. This form is used by the Oklahoma Workers’ Compensation Commission for medical professionals who wish to be appointed to the list of Independent Medical Examiners (IME). These examiners provide impartial and objective medical evaluations in workers’ compensation cases. The form requires applicants to submit personal and professional information, including their medical degree, board certifications, licensure details, and years of practice. Additionally, applicants must specify their specialties, any medical cases they do not wish to handle, and their hospital privileges or teaching positions. The form also requires disclosure of any past disciplinary actions, license suspensions, or felony convictions. Applicants must attach proof of professional liability insurance and any Independent Medical Examiner training they have completed. By signing the form, applicants agree to abide by workers’ compensation rules and procedures, conduct timely evaluations, and submit reports within the required timeframe. If approved, they will serve as an IME for a two-year term and accept set fees for their services as determined by the Commission. The application must be submitted with a current Curriculum Vitae (CV) and a completed CC-FORM-17 (Disclosure Statement) to the Commission’s Health Services Division in Tulsa, Oklahoma. www.FormsWorkflow.com