Independent Examiners Report Of Request For Information Or Response To Request Regarding Ind Med Exam {IME-3}

NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205 State of New York WORKERS' COMPENSATION BOARD INDEPENDENT EXAMINER'S REPORT OF REQUEST FOR INFORMATION/RESPONSE TO REQUEST REGARDING INDEPENDENT MEDICAL EXAMINATION 1. INDEPENDENT EXAMINER'S NAME AND ADDRESS 2. NAME AND ADDRESS OF PARTY REQUESTING INFORMATION 3. INDEPENDENT EXAMINER'S IME AUTHORIZATION NO. 4. IME ENTITY REGISTRATION NO. (If Applicable) 5. DATE OF INDEPENDENT MEDICAL EXAMINATION 6. CLAIMANT'S NAME 7. CLAIMANT'S WCB CASE NO. 8. DATE OF INJURY 9. DATE OF THIS REPORT Pursuant to Section 137 of the Workers' Compensation Law (WCL), if an independent examiner who has performed or will be performing an independent medical examination of a workers' compensation claimant receives a request for information regarding the claimant, including faxed or electronically-transmitted requests, the independent examiner must submit a copy of the request for information to the Workers' Compensation Board within ten days of the receipt of the request. In addition, copies of all responses to such requests, shall be submitted by the responding independent examiner to the Board within ten days of the submission of the response to the requester. PLEASE NOTE: Do not use this form to file documents, records, reports or items that are part of the official Board file. Any such items that are not part of the Board file at the time the IME is scheduled, should be submitted to the Board at the time of scheduling. The IME-3 should not be used for such submissions. If the request for information is limited to a request for scheduling of an independent medical examination, you need not file this form. However, you must send a copy of Form IME-5 ("Claimant's Notice of Independent Medical Examination") to the Workers' Compensation Board. Instructions: a. Complete all identifying information, items 1-9 above. b. To report a request for information, complete item 10-A below, sign, date and mail to the Workers' Compensation Board within ten days of receipt of request. A copy of the request must be attached. c. To report independent examiner's response to a request for information, complete item 10-B below, sign, date and mail to the Workers' Compensation Board within ten days of submission of response to the requester. A copy of the response must be attached. d. If the independent examiner responds to the requester within ten days of the receipt of the request, complete, sign and date items 10-A and 10-B and mail to the Workers' Compensation Board within ten days of receipt of the request, with copies of the request and response attached. Otherwise, submit separate forms to report request and your response within the time limits given in b. and c. above. NOTE: The independent examiner's release of medical and/or workers' compensation records to the Board and/or to the requesting party is subject to applicable laws regarding the confidentiality of such records, including but not limited to Section 110-a of the Workers' Compensation Law, Section 18 of the Public Health Law, and other applicable state and federal laws. HIPAA Notice: In order to adjudicate a workers' compensation claim, WCL Sections 13-a and 137 permit an employer or carrier to have a claimant examined by a health care provider. Pursuant to 45 CFR 512 a health care provider who has been retained by an employer or carrier to evaluate a workplace injury is exempt from HIPAA's restrictions on disclosure of health information. INDEPENDENT EXAMINERS WHO FAIL TO FILE REQUIRED FORMS MAY BE SUBJECT TO DISCIPLINE, INCLUDING REMOVAL OF AUTHORIZATION TO PERFORM INDEPENDENT MEDICAL EXAMINATIONS. 10-A. INDEPENDENT EXAMINER'S REPORT OF REQUEST FOR INFORMATION REGARDING INDEPENDENT MEDICAL EXAMINATION Date request received ____________________________________________________ Attached is a copy of a request for information received in the case identified above. _______________________________________ __________________________________ _______________________ Independent Examiner's Name Signature Date 10-B. INDEPENDENT EXAMINER'S REPORT OF RESPONSE TO REQUEST FOR INFORMATION REGARDING INDEPENDENT MEDICAL EXAMINATION Date response submitted to requester ________________________________________ Attached is a copy of my response to a request for information received in the case identified above, and all materials supplied to the requester which are not already part of the official case record. _______________________________________ ___________________________________ _______________________ Independent Examiner's Name Date Signature IME-3 (7-14) www.wcb.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com