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Application For Independent Medical Exam-Medical Service Provider Authorization 3930 - Oregon
|Application For Independent Medical Exam-Medical Service Provider Authorization Form. This is a Oregon form and can be used in Medical Workers Comp .||
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Application for Independent Medical Exam Medical Service Provider Authorization Workers' Compensation Division Please print Name: (Last) (First) (M.I.) Medical specialty: Chiropractic General surgery Heart specialist (State) (ZIP) Orthopedic surgery Otolaryngology Physiatry Physical medicine Plastic surgery Psychiatry Psychology Other (specify) Physical work location: (City) Internal medicine Neurology Neurosurgery Occupational medicine Mailing address, if different: (City) (State) (Work) (ZIP) (Contact number, if different) Phone: Licensing board: Medical license number: Are you certified by any specialty boards? If so, please list: Subspecialties (list): Type of exam you are willing to perform: (See back of form for descriptions.) IME WRME Both Check the geographical areas where you are willing to perform exams: (See back of form for area descriptions.) Portland Metro Eugene Metro Mid-Oregon Coast Columbia Gorge Central Oregon Salem Metro Northern Oregon Coast Southern Oregon Coast Northeastern Oregon Southern Oregon Other: (Please specify) Please provide the following: I have attended an approved IME/WRME training. I will complete the training at a future date. Please provide the date and the name of the vendor. We will verify your attendance and process your application. (Date) (Vendor name) By my signature, I certify that all answers and statements on this application are true and complete to the best of my knowledge. I agree to abide by the standards of professional conduct for IMEs/WRMEs adopted by my licensing board or, if my licensing board has not adopted standards, the examination standards published in Oregon Administrative Rule (OAR) 436-010-0265 Appendix C and reprinted on the back of this form, and all relevant Oregon workers' compensation laws and rules. I will provide independent, objective, and timely medical opinions for all exams I conduct. I understand approval of my application places me on the list of providers authorized to perform IMEs/WRMEs. I also understand that approval of my application does not guarantee me any work. Signature: For assistance with this form, please contact the IME coordinator at (503) 947-7583. Send this completed form to: Workers' Compensation Division Medical Section Attn: IME coordinator P.O. Box 14480 Salem, OR 97309-0405 Date: Keep a copy of this form for your records. 440-3930 (6/07/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkflow.com Independent medical examination (IME): A medical examination of an injured worker by a medical provider other than the worker's attending physician at the request of an insurer. This includes physical capacity evaluations and work capacity evaluations, if requested by the insurer. The insurer or selfinsured employer pays for this examination. Worker-requested medical exam (WRME): An examination available at the worker's request when the insurer has denied the worker's claim for compensability based upon an IME and when certain criteria are met. The insurer or self-insured employer pays for this examination. Geographic areas Portland Metro includes: Portland, Beaverton, Clackamas, Gladstone, Gresham, Hillsboro, Lake Oswego, Milwaukie, Oregon City, Scappoose, St. Helens, Tigard, Troutdale, Tualatin, West Linn Salem Metro includes: Salem/Keizer, Albany, Corvallis, Dallas, McMinnville, Monmouth/Independence, Stayton, Sublimity, Willamina, Woodburn Eugene Metro includes: Eugene, Cottage Grove, Roseburg, Springfield Northern Oregon Coast includes: Astoria, Nehalem, Tillamook, Warrenton Mid-Oregon Coast includes: Lincoln City, Newport, Toledo Southern Oregon Coast includes: Bandon, Brookings, Coos Bay/North Bend, Coquille, Florence, Gold Beach, Port Orford, Reedsport Columbia Gorge includes: Boardman, Cascade Locks, Hood River, The Dalles Northeastern Oregon includes: Baker City, Hermiston, LaGrande, Milton-Freewater, Ontario, Pendleton, Umatilla, Vale Central Oregon includes: Bend, Madras, Prineville, Redmond, Sisters Southern Oregon includes: Ashland, Central Point, Grants Pass, Klamath Falls, Medford Other includes: Any location not described above The standards of professional conduct for performing IMEs adopted by the relevant health professional regulatory board, if any, apply. If the health professional regulatory board does not adopt standards, the Independent Medical Examination Standards published as Appendix C in OAR 436-010-0265 apply. IME standards 1. 2. 3. 4. 5. Communicate honestly with the parties involved in the examination. Conduct the examination with dignity and respect for the parties involved. Identify yourself to the examinee as an independent examining physician. Verify the examinee's identity. Discuss the following with the examinee before beginning the examination: a. Remind the examinee of the party who requested the examination. b. Explain to the examinee that a physician-patient relationship will not be sought or established. c. Tell the examinee the information provided during the examination will be documented in a report. d. Review the procedures that will be used during the examination. e. Advise the examinee a procedure may be terminated if the examinee feels the activity is beyond the examinee's physical capacities or when pain occurs. f. Answer the examinee's questions about the examination process. During the examination: a. Ensure the examinee has privacy to disrobe. b. Avoid personal opinions or disparaging comments about the parties involved in the examination. c. Examine the condition being evaluated sufficient to answer the requesting party's questions. d. Let the examinee know when the examination has concluded, and ask if the examinee has questions or wants to provide additional information. Provide the requesting party a timely report that contains findings of fact and conclusions based on medical probabilities for which the physician is qualified to express an opinion. Maintain the confidentiality of the parties involved in the examination subject to applicable laws. At no time provide a favorable opinion based solely or in part upon an accepted fee for service. American LegalNet, Inc. www.FormsWorkflow.com 6. 7. 8. 9.