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Approved Examiner Update F245-051-000 - Washington

Approved Examiner Update Form. This is a Washington form and can be used in Independent Medical Exam (IME) Workers Comp .
 Fillable pdf Last Modified 3/13/2008
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Approved Examiner Update Please check all that apply and return the signed/dated form to: Provider Review and Education PO Box 44322 Olympia, WA 98504-4322 Fax (360) 902-4249 I am available to conduct independent medical examinations. Do not remove my name from the Approved Examiners List. I am temporarily unavailable to conduct independent medical examinations. Do not remove my name from the Approved Examiners List. I will be available to schedule appointments after ____________________. Date I am not available to conduct independent medical examinations. Please remove my name from the Approved Examiners List and inactivate my IME provider number. I have been informed that if my name is vluntarilo y removed from the list I may reapply in the future. Any future application will be subject to approval criteria in use at the time of the application. Please correct contact information listed on the website at www.imes.lni.wa.gov. Examiner name: _____________________________________________ Examiner mailing address: _____________________________________________ _____________________________________________ Examiner contact phone: ______________________ To change IME Firm affiliation or examsite availability or address please call: (360) 902-6815. My direct patient care status (excluding IMEs) has changed to (circle): Full-time Part-time (under 32 hrs/week) Limited (8 or less hrs/week) Retired as of ___________________________ Date Print name: ___________________________________________________________________ Signature: _______________________________________________ Date: __________ F245-051-000 approved examiners list update 8-04
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