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 .
 Fillable pdf Last Modified 12/29/2005
Get this form for FREE as a print-only pdf

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
Link/Embed this Document

Popular Searches

  1. proof of service of summons
  2. Petition to Expunge
  3. Income and Expense Declaration
  4. writ of replevin
  5. fee waiver
  6. Notice and Acknowledgment of Receipt
  7. proof of claim
  8. divorce forms
  9. abstract of judgment
  10. form interrogatories

Bookmark and Share