SECOND INDEPENDENT MEDICAL EVALUATION (SIME) FORM INSTRUCTIONS: (1) Complete all applicable sections of this form ON BOTH SIDES, (2) list the specifics which reflect the SIME dispute in columns four and seven, (3) file this form and one copy of the medical reports reflecting the medical dispute with the appropriate Board office in accordance with 8 AAC 45.072 and (4) file a Request for Conference form. If this form is not signed by all parties, the party preparing this form must serve a copy of this form and the attachments upon all other parties in accordance with 8 AAC 45.060. Employee's Name: Body Parts in Dispute: Attending Physician(s) Names: 1. 2. 3. 1 Dispute(s) / Issue(s) 2 Phy No. 3 Report Date 4 Medical Opinion (include report page and item/paragraph #) Employer's Name: Date of Injury: AWCB Case Number: Employer Independent Medical Evaluation (EIME) Physician(s) Names: 1. 2. 3. 5 Phy No. 6 Report Date 7 Medical Opinion (include report page and item/paragraph #) Causation: Compensability: Treatment (List disputed time periods in Col 4 & 7) Degree of Impairment (State the percent of impairment in Col 4 & 7) Functional Capacity (Attach job description) Medical Stability (List disputed time periods in Col 4 & 7) CONTINUED ON BACK American LegalNet, Inc. www.FormsWorkFlow.com Form 07-6147 (Rev 02/2010) SECOND INDEPENDENT MEDICAL EVALUATION (SIME) FORM (Continued from Front) 1 Dispute(s) / Issue(s) Ability to Enter a Reemployment Plan (Attach plan) 2 Phy No. 3 Report Date 4 Medical Opinion (include report page and item/paragraph #) 5 Phy No. 6 Report Date 7 Medical Opinion (include report page and item/paragraph #) Non-SIME Issues(s) (AS 23.30.110 (g) request) What medical speciality is required for the SIME? Please indicate if the parties have stipulated to a speciality? SIME physician? If yes, list the speciality(ies) and/or physician(s): Has the employee been seen by any physicians on the Board's SIME list of examiners or at any facility where the SIME physicians practice? If yes, list the physicians. The Board's list of examiners can be obtained at www.labor.alaska.gov/wc or by contacting the Division at (907) 269-4980 Anchorage, (907) 451-2889 Fairbanks or (907) 465-2790 Juneau. Has the employer used any physicians on the SIME list or the practice at which the SIME physicians treat during the past 12 months? If yes, list the physicians. Employee Employer (Each party must check applicable boxes. If the parties agree on any statement below, it constitutes a stipulation under 8 AAC 45.050.) Based upon the above information, an SIME dispute exists under AS 23.30.095(k). The right to have the board determine the need for an SIME is waived. A workers' compensation officer or the board designee may decide whether or not to order an SIME. Non-SIME issues, noted above, should be submitted to the board's examiner under AS 23.30.110(g). The right to have the board require an examination is waived. A workers' compensation officer or the board's designee may decide whether or not to order an examination, in conjunction with an SIME, under AS 23.30.110(g). The employer will pay for the cost of this examination. An examination by the board's examiner is considered to be an SIME. No subsequent SIME will be ordered on the non-SIME issues noted above. This form amends the issues in an active application or petition previously filed by a party. The requirement to serve and file an answer to the application or petition as amended by this SIME form, is waived. IF THERE IS NO ACTIVE APPLICATION OR PETITION IN THIS CASE, THE PARTY PREPARING THIS FORM MUST ATTACH AN APPLICATION OR PETITION TO COMMENCE PROCEEDINGS. Signature(s) Employee or Representative Date Employer, Insurer or Representative Date American LegalNet, Inc. www.FormsWorkFlow.com Form 07-6147 (Rev 02/2010)