Washington > Workers Comp > Independent Medical Exam (IME)
Independent Medical Exam Comments F245-053-000 - Washington
| Independent Medical Exam Comments Form. This is a Washington form and can be used in Independent Medical Exam (IME) Workers Comp . |
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Department of Labor and Industries INDEPENDENT MEDICAL Provider Review & Education Unit PO Box 44322 Olympia WA 98504-4322 EXAM COMMENTS Please use the block below to provide us your comments, positive or negative, about your recent IME. Thank you. Date of Exam: Claim # IME Company Name (if known) Name of Doctor(s)(if known) (1) (2) Comments: (please be specific) Date Signature American LegalNet, Inc.F245-053-000 IME comments - English 12-04 www.USCourtForms.com
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