Original Notice And Petition Concerning Independent Medical Examination {14-0007}

Form 100A (14-0007) - ORIGINAL NOTICE & PETITION CONCERNING INDEPENDENT MEDICAL EXAMINATION. This form is used in Iowa workers’ compensation cases when a claimant seeks an independent medical examination (IME) at the employer’s expense under Iowa Code section 85.39. It serves as a formal notice and petition to the employer and/or insurance carrier, informing them that the claimant believes the evaluation of permanent disability performed by the employer’s physician is too low. The claimant requests an IME by a different physician and asks the employer to cover the reasonable costs of the examination, including transportation expenses. The form includes details about the injury, affected body parts, the physician who conducted the initial evaluation, and the requested IME. The employer must file an answer or respond within 20 days, or a default judgment may be entered. The claimant may also choose to waive or request an evidentiary hearing. www.FormsWorkflow.com