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Independent Examiners Report of Independent Medical Examination IME-4 - New York

Independent Examiners Report of Independent Medical Examination Form. This is a New York form and can be used in Workers Compensation .
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STATE OF NEW YORK - WORKERS' COMPENSATION BOARD INDEPENDENT EXAMINER'S REPORT OF INDEPENDENT MEDICAL EXAMINATION A copy of each report of Independent Medical Examination shall be submitted on the same day and in the same manner to the Workers' Compensation Board, the insurance carrier or self-insured employer, the claimant's attending physician or other attending independent examiner, the claimant's representative, if any, and the claimant. CHECK ONE: PHYSICIAN PODIATRIST CHIROPRACTOR PSYCHOLOGIST CLAIMANT THIS EXAMINATION WAS REQUESTED BY: WCB CASE NO. CARRIER CASE NO. (IF KNOWN) DATE OF INJURY CARRIER/EMPLOYER INJURED PERSON'S SOCIAL SECURITY NUMBER ADDRESS (Include Apt. No.) DATE OF EXAMINATION INJURED PERSON EMPLOYER INSURANCE CARRIER (First Name) (Middle Initial) (Last Name) IF EXAMINER CONDUCTED THIS EXAMINATION AS AN EMPLOYEE OF AN IME COMPANY, OR UNDER CONTRACT OR ARRANGEMENT WITH AN IME COMPANY, STATE NAME AND WORKERS' COMPENSATION BOARD REGISTRATION NUMBER OF IME COMPANY. Results of Examination (continue on reverse or attach additional sheets, if necessary) I hereby certify that this report is a full and truthful representation of my professional opinion with respect to the claimant's condition; that no person or entity has caused, directed or encouraged me to submit a report that differs substantially from my professional opinion; and I have reviewed the report and attest to its accuracy. ________________________________________________ __________________________________________________ ____________________________ Independent Examiner's Name Independent Examiner's Signature Date ____________________________________________________________________________________ Independent Examiner's Address ________________________________________ IME Authorization No. NO INDEPENDENT EXAMINER EXAMINING OR EVALUATING A CLAIMANT UNDER THE WORKERS' COMPENSATION LAW NOR ANY SUPERVISING AUTHORITY OR PROPRIETOR NOR INSURANCE CARRIER OR EMPLOYER MAY CAUSE, DIRECT OR ENCOURAGE A REPORT TO BE SUBMITTED AS EVIDENCE IN WORKERS` COMPENSATION CLAIM ADJUDICATION WHICH DIFFERS SUBSTANTIALLY FROM THE PROFESSIONAL OPINION OF THE EXAMINING INDEPENDENT EXAMINER. SUCH AN ACTION SHALL BE CONSIDERED WITHIN THE JURISDICTION OF THE WORKERS` COMPENSATION FRAUD INSPECTOR GENERAL AND MAY BE REFERRED AS A FRAUDULENT PRACTICE. IME-4 (7-14) American LegalNet, Inc. www.FormsWorkFlow.com Results of Examination (continued) It is unlawful for any person who has obtained individually identifiable information from Workers' Compensation Board records to disclose such information to any person who is not otherwise lawfully entitled to obtain these records. Any person who knowingly and willfully obtains workers' compensation records which contain individually identifiable information under false pretenses or otherwise violates Workers' Compensation Law Section 110-a shall be guilty of a class A misdemeanor and shall be subject upon conviction, to a fine of not more than one thousand dollars. HIPAA Notice: In order to adjudicate a workers' compensation claim, WCL Sections 13-a and 137 permit an employer or carrier to have a claimant examined by a health care provider. Pursuant to 45 CFR 512 a health care provider who has been retained by an employer or carrier to evaluate a workplace injury is exempt from HIPAA's restrictions on disclosure of health information. Reports should be sent directly to the Workers' Compensation Board at the address listed below: NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205 Customer Service Toll-Free Line: 877-632-4996 Statewide Fax Line: 877-533-0337 IME-4 Reverse (7-14) THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION www.wcb.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com
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