RETURN TO: OFFICE OF WORKERS' COMPENSATION, ATTN: Medical Services POST OFFICE BOX 94040 BATON ROUGE, LA 70804-9040 (225) 342-7559 TOLL FREE (800) 201-2494 1. Social Security No . 2. Date of Injury/Illness 3. Part(s) of Body to be evaluated 4. Date of Birth 5. OWC Docket Number 6. OWC District Number - - 7. Claim # __________________________________ REQUEST FOR INDEPENDENT MEDICAL EXAMINATION NOTE: THIS REQUEST WILL NOT BE HONORED UNLESS A DISPUTE HAS ARISEN AS TO CONDITION OF THE EMPLOYEE AS PER L.R.S. 23:1123. 8. This form is submitted by: Employee A. B. C. D. Employer Insurer TPA/Self Insurance Fund The choice of the medical practitioner shall be that of the Director of the Office of Workers' Compensation as per L.R.S. 23:1123. A cover letter outlining the conflicting medical issue(s) in dispute (reason for request) along with the conflicting medical reports must be attached to this form. A list of names, addresses, phone numbers and reports of all physicians/medical providers who have treated or examined the injured employee for this injury must be included. Indicate who chose each health care provider. A copy of this request must be signed, dated and mailed to all parties. EMPLOYEE 9. Name Street or Box City State Phone ( ) Zip 10. Name EMPLOYEE'S ATTORNEY Street or Box City State Phone ( ) Zip Fax ( EMPLOYER 11. Name Street or Box City State Phone ( ) EMPLOYER / INSURER'S ATTORNEY ( circle one ) ) _________________________________ INSURER / ADMINISTRATOR ( circle one ) 12. Name Adjuster Name _________________________________ Street or Box City Zip State Phone ( ) Zip Fax ( ) ________________________________ 13. Name ________________________________________ Street or Box __________________________________ City__________________________________________ State Zip ________ Signature of Applicant Date Phone ( )__________________________________ Fax ( ) ___________________________________ LWC-WC 1015 REVISED 10/14 American LegalNet, Inc. www.FormsWorkFlow.com