Louisiana > Workers Comp
Request For Independent Medical Examination WC 1015 - Louisiana
| Request For Independent Medical Examination Form. This is a Louisiana form and can be used in Workers Comp . |
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RETURN TO: OFFICE OF WORKERS' COMPENSATION POST OFFICE BOX 94040 BATON ROUGE, LA 70804-9040 (225) 342-7559 TOLL FREE (800) 201-2494 1. Social Security No . 2. Date of Injury/Illness 3. Part(s) of Body Injured 4. Date of Birth 5. OWC Docket Number 6. OWC District Number - - REQUEST FOR INDEPENDENT MEDICAL EXAMINATION NOTE: THIS REQUEST WILL NOT BE HONORED UNLESS A DISPUTE HAS ARISEN AS TO CONDITION OF THE EMPLOYEE AS PER L.R.S. 23:1123. 7. This form is submitted by: __ Employee A. B. C. D. __ Employer __ Insurer __ TPA/Self Insurance Fund The choice of the medical practitioner shall be that of the Director of the Office of Workers' Compensation as per L.R.S. 23:1123. A cover letter outlining the conflicting medical issue(s) in dispute (reason for request) along with the conflicting medical reports must be attached to this form. A list of names, addresses, phone numbers and reports of all physicians/medical providers who have treated or examined the injured employee for this injury must be included. Indicate who chose each health care provider. A copy of this request must be mailed to all parties. EMPLOYEE 8. Name Street or Box City State Phone ( ) EMPLOYER 10. Name Street or Box City State Phone ( ) EMPLOYER / INSURER'S ATTORNEY ( circle one ) EMPLOYEE'S ATTORNEY 9. Name Street or Box City Zip State Phone ( ) INSURER / ADMINISTRATOR ( circle one ) Zip 11. Name Street or Box City Zip State Phone ( ) Zip 12. Name Street or Box City State Phone ( ) Zip Signature of Applicant Date LWC-WC 1015 REVISED 07/08 American LegalNet, Inc. www.FormsWorkflow.com
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