IME Observer Form {3923a}

IME Observer Form I, Print worker's name Workers' compensation claim number: want to have an observer with me in the independent . Date medical exam scheduled for By signing below, I understand that: 1. I may be asked sensitive questions during the exam in front of my observer; 2. If my observer interferes with the exam, the health care provider may stop the exam, which could affect my benefits; and 3. My observer cannot be paid to attend the exam with me. Worker's signature 440-3923a (9/08/DCBS/WCD/WEB) Date American LegalNet, Inc. www.FormsWorkFlow.com