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Claimants Notice Of Independent Medical Examination IME-5 - New York

Claimants Notice Of Independent Medical Examination Form. This is a New York form and can be used in Workers Compensation .
 Fillable pdf Last Modified 9/11/2013
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State of New York WORKERS' COMPENSATION BOARD CLAIMANT'S NOTICE OF INDEPENDENT MEDICAL EXAMINATION under Section 137 WCL WCB CASE NUMBER CARRIER CASE NUMBER DATE OF ACCIDENT DATE OF THIS NOTICE CLAIMANT'S NAME AND ADDRESS INSURANCE CARRIER'S NAME AND ADDRESS DATE OF EXAMINATION PLACE OF EXAMINATION THIS EXAMINATION WAS REQUESTED BY TIME OF EXAMINATION IF THIS EXAMINATION WAS REQUESTED BY THE CLAIMANT, THE CLAIMANT MAY BE RESPONSIBLE FOR PAYMENT OF THE COST OF THE EXAMINATION. THE COST OF THIS EXAMINATION WILL BE: (Health provider must indicate exact fee or fee range.) Exact fee: $________________________________ Fee range: From $____________________ to $____________________ THE PRACTITIONER INTENDS DOES NOT INTEND TO RECORD OR VIDEOTAPE THIS EXAMINATION. (This notice is invalid if this item is not completed.) Purpose of Examination/Special Instructions: You have been scheduled for an independent medical examination in connection with your workers' compensation claim at the time and place indicated above. YOUR RECEIPT OF BENEFITS COULD BE DENIED, TERMINATED OR REDUCED AS A RESULT OF A DETERMINATION WHICH MAY BE BASED ON A MEDICAL EVALUATION MADE AFTER THIS MEDICAL EXAMINATION. You have the right to videotape or otherwise record the examination. You also have the right to be accompanied during the exam by an individual or individuals of your choosing. See the reverse of this form for a complete statement of your rights and obligations under the law with regard to independent medical examinations. If for any reason you are unable to appear for this examination, contact______________________ Name at __________________________ as soon as possible. Telephone Number IME-5 (1-11) American LegalNet, Inc. www.FormsWorkFlow.com STATEMENT OF RIGHTS AND OBLIGATIONS - INDEPENDENT MEDICAL EXAMINATIONS - Section 137 WCL 1. The claimant must receive notice by mail of the scheduled independent medical examination at least seven business days prior to such examination. The notice must advise the claimant if the practitioner intends to record or videotape the examination. 2. If the examination was requested by the claimant, the claimant may be responsible for the cost of the examination, and the health provider must indicate on the notice of examination the actual fee or the fee range for the examination. 3. All independent medical examinations shall be performed in medical facilities suitable for such exam,with due regard and respect for the privacy and dignity of the injured worker/claimant. 4. Examination facilities must be provided in a safe, convenient and accessible location within a reasonable distance from the claimant's residence. Examinations will be held during regular business hours, except with the consent and for the convenience of the claimant. 5. All independent medical examinations shall be performed by a practitioner competent to evaluate or examine the injury or disease from which the claimant suffers. A practitioner is not eligible to perform an independent medical examination of a claimant if the practitioner has treated or examined the claimant for the condition for which the examination is being requested, or if another member of the preferred provider organization or managed care provider to which the practitioner belongs has treated or examined the claimant for the condition for which the examination is being requested. 6. The claimant has the right to videotape or otherwise record the examination. 7. The claimant has the right to be accompanied during the examination by an individual or individuals of his/her choosing. 8. The claimant has the right to be reimbursed for travel expenses to and from the examination site, if the examination was requested by the insurance carrier or employer. 9. A copy of each report of independent medical examination shall be submitted by the practitioner on the same day and in the same manner to the Workers' Compensation Board, the insurance carrier, the claimant's attending physician or other attending practitioner, the claimant's representative, if any, and the claimant. 10. The claimant's receipt of benefits could be denied, terminated, or reduced as a result of a determination, made by the Workers' Compensation Board, which may be based upon a medical evaluation made after an independent medical examination. However, the ability of the claimant to appear for an examination or hearing shall not in itself determine questions of disability, extent of disability or eligibility for benefits. 11. In any open case where an award has been directed by the Board for temporary or permanent disability at an established rate of compensation, and there is a direction by the Board for continuation of payments, or any closed case where an award for compensation has been made for permanent total or permanent partial disability, a report of an independent medical examination shall not be the basis for suspending or reducing payments unless and until the rules and regulations of the Board regarding suspending or reducing payments have been met and there is a determination by the Board finding that such suspension or reduction is justified. 12. The claimant has the right to appeal any Workers' Compensation Board determination, including determinations based on an independent medical examination. The Board's notice of decision contains full instructions and time limitations for filing an appeal. DECLARACIÓN DE DERECHOS Y OBLIGACIONES - EVALUACIONES MÉDICAS INDEPENDIENTES - WCL Artículo 137 1. El reclamante debe recibir notificación por correo de la evaluación médica independiente programada con una anticipación de al menos siete días laborales previos a dicho examen. La notificación debe avisarle al reclamante si el médico intentará grabar o filmar la evaluación. 2. Si el reclamante solicitó la evaluación, el reclamante podría ser responsable del costo del examen y el proveedor de servicios de salud puede indicar en la notificación de la evaluación los honorarios exactos o aproximados del examen. 3. Todas las evaluaciones médicas independientes se realizarán en establecimientos médicos adecuados para dichos exámenes con el debido respeto y consideración por la privacidad y dignidad del reclamante o trabajador lesionado. 4. Los establecimientos en que se realicen las evaluaciones deben estar ubicados en un lugar seguro, conveniente y accesible dentro de una distancia razonable de la residencia del reclamante. Las evaluaciones se llevarán a cabo en horario no
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