New York > Workers Compensation
Health Providers Application For Authorization Under Workers Compensation Law MR IME-1 - New York
| Health Providers Application For Authorization Under Workers Compensation Law Form. This is a New York form and can be used in Workers Compensation . |
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State of New York CHECK ONE: CHECK ONE: WORKERS COMPENSATION BOARD THIS AGENCY EMPLOYS AND SERVES q Physician q Initial Authorization Office of Health Provider Administration PEOPLE WITH DISABILITIES WITHOUT q Podiatrist q Reinstatement DISCRIMINATION q Chiropractor q Change in Rating 100 Broadway-Menands q Psychologist (Physician only) Albany, NY 12241 1-800-781-2362 HEALTH PROVIDERS APPLICATION FOR AUTHORIZATION UNDER THE WORKERS COMPENSATION LAW IMPORTANT INSTRUCTIONS TO HEALTH PROVIDERS Complete both sides of this application. Do not fill in shaded area. All entries are to be typewritten or printed clearly. Illegible applications will be returned to the applicant. Physicians: Submit in duplicate to your County Medical Society. Osteopathic physicians may submit to their County Medical Society or the New York State OsteopathicMedical Society. A copy of the application (face sheet only) must be filed with the Workers Compensation Board at the above address at the same time it is submitted to theMedical Society. Other Health Providers: Submit to appropriate committee (Podiatry Practice Committee, Psychology Practice Committee, or Chiropractic Practice Committee) at the aboveaddress. The undersigned hereby makes application to be authorized by the Chair, Workers Compensation Board for the following: CHECK ALL THAT APPLY To render appropriate care to persons suffering injury or illness in accordance with the Workers Compensation Law (WCL), to volunteer firefighters in accordance with the Volunteer Firefighters Benefit Law (VFBL) and volunteer ambulance workers in accordance with the Volunteer Ambulance Workers Benefit Law (VAWBL), and requests the following rating (physicians only)___________________________________ . To conduct independent medical examinations (IMEs) of persons suffering work-related injury or illness under the WCL, VFBL and VAWBL. 1. Name____________________________________________________________________ _____ Date of Birth__________________________________ 2. Home Address_________________________________________________________________ ______________________________________________ County__________________________________________________________________ _ Home Telephone Number____________________________ 3. New York State Professional License Number____________________________________ Date License Granted________________________________ 4. Office Address(es): List below all of your offices of practice in New York State. Attach an additional sheet of paper if necessary. For each address listed below, you must have a valid registration certificate from the New York State Education Department. If any of your office addresses are not currently registered, please call the Division of Professional Licensing Services at (518) 474-3817. Be advised that any address registered with the Education Department will be given out to claimants. Principal Office Address_________________________________________________________________ ______ Office Tel. No.____________________ Street City County Zip Code Other Office Address_________________________________________________________________ _________Office Tel. No. ____________________ Street City County Zip Code 5. Major Hospital Affiliations in New York State: A. Hospital________________________________________________________________ _________ Zip Code_________________________________ Clinical Service_______________________________________ Positions Held_________________________Date____________________________ B. Hospital________________________________________________________________ __________ Zip Code_________________________________ Clinical Service_______________________________________ Positions Held_________________________Date____________________________ 6. Current Professional Society Memberships: q County Medical Society: County of ____________________________________________ q American Medical Association q Specialty Societies _________________________________________________________ q Medical Society of the State of New York q Board Certification, American Board of Medical Specialties q New York State Osteopathic Medical Society q Board Certification, American Osteopathic Association q Board Certification, Other ____________________________________________________ Physicians seeking authorization to conduct Independent Medical Examinations (IMEs) must be board certified by a medical or osteopathic specialty board that is recognized by the Workers Compensation Board. 7. Graduate of (Professional School) ________________________________________________Degree _____________________ Year _____________ 8. Post-graduate study in College or Hospital________________________________________________________________ _______________________ 9. All psychologists, podiatrists, chiropractors, please attach curriculum vitae including academic training, supervision and experience. 10. Have you completed an authorized or approved residency? q Yes q No If "yes," attach a copy of the certificate of completion or a letter from a hospital administrator confirming completion of approved residency. 11. If you have been certified by any specialty board, specify board and date of certification below and attach proof of certification: a. ___________________________________ Date__________________ b. __________________________________ Date___________________ For Office Use Only - Do Not Fill in Shaded Area a. 1 3 Rating(s) Given By:______________ Status b. Date of Current Rating 2 4 Med. Reg. Sec. MR/IME-1 (4-05) Continued on Reverse www.wcb.state.ny.us American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 212. Are you employed by any health provider, organization, commercial firm, union or hospital to render care or conduct independent medical examinations? q Yes q No If "Yes," explain_________________________________________________________________ _______________________________ ________________________________________________________________________ ____________________________________________________13. Are you presently, or were you previously, authorized to (a) render care under the Workers Compensation Law? q Yes q No If "Yes", give date and authorization number:______________________________ (b) conduct independent medical examinations? q Yes q No If "Yes", give date and authorization number:_____________________________ 14. Have you ever previously applied for authorization to render care or conduct independent m
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