Termination Of Benefits-Request For IME {38911}

State Form 38911 - TERMINATION OF BENEFITS/REQUEST FOR IME. This form is used by employers, claim administrators, and injured workers involved in a workers’ compensation case in Indiana. This form serves two primary purposes. First, it allows the employer or claims administrator to formally notify the Indiana Worker’s Compensation Board and the injured worker of the termination of Temporary Total Disability (TTD) or Temporary Partial Disability (TPD) benefits. Termination must be based on specific legal reasons outlined in Indiana Code § 22-3-3-7(d), such as the injured worker returning to work, refusing medical examination or suitable employment, death, receiving maximum compensation, or being unable to work due to unrelated reasons. Second, the form provides injured workers with an opportunity to dispute the termination and request an Independent Medical Examination (IME) if they believe further medical care is needed or if the termination is unjustified. The worker must respond within seven days and may do so electronically through the Board's website. Both parties are required to certify service of the form and any supporting documents, ensuring due process is followed in benefit determinations and disputes. www.FormsWorkflow.com