Oregon > Workers Comp > Request For Review Of Decision Or Resolution Of Dispute
Insurers Request For Director Approval Of Insurer Medical Examination 2333 - Oregon
| Insurers Request For Director Approval Of Insurer Medical Examination Form. This is a Oregon form and can be used in Request For Review Of Decision Or Resolution Of Dispute Workers Comp . |
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Workers' Compensation Division Insurer's Request for Director Approval of an Additional Independent Medical Examination Phone: WORKER INFORMATION Worker name: Address: Date of injury: Insurer: Claim no.: INDEPENDENT MEDICAL EXAMINATION (IME) INFORMATION 1. State the reasons you are requesting an additional IME and the conditions you wish to have evaluated. Note: Include any medical documentation you would like to have considered in this matter. (Use the back of this form or attach additional sheets if necessary.) 2. 3. 4. What was the date of the last IME to evaluate this condition? Date: How many IMEs has the worker attended since the claim was last opened? Attach copies of previous IME notification letters for this open period. If you cannot provide copies, list all examinations in chronological order, with the names of the examiners, time, date, place, and conditions evaluated. (Use the back of this form or attach additional sheets, if necessary). CERTIFICATION STATEMENT By signing below, I certify that I: · Have answered all questions to the best of my ability. · Have attached sufficient documentation to support the request (See Bulletin 252). · Will provide a copy of this request to the worker and the worker's attorney (if represented). Signature: Send a completed and signed copy of this form and all accompanying documents to: Workers' Compensation Division, Medical Section, Resolution Team 350 Winter St. NE, P.O. Box 14480 Salem, OR 97309-0405 Date: NOTICE TO THE WORKER If you object to the request for an additional independent medical examination (IME), send your objections within 10 days from the date of this request to: Workers' Compensation Division, Medical Section, Resolution Team 350 Winter St. NE P.O. Box 14480 Salem OR 97309-0405 Otherwise, the director will approve or disapprove the insurer's request based on available information only. For more information, contact the Resolution Team at (503) 947-7816 (select option 2), e-mail wcd.medicalquestions@state.or.us, or visit our Web site: www.wcd.oregon.gov. 440-2333 (8/07/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkflow.com
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