Independent Medical Examiner Application For Appointment Nebraska Workers’ Compensation Court State Capitol Building P. O. Box 98908 Lincoln, NE 68509-8908 402-471-6468 or 800-599-5155 402-471-2700 (FAX) http://www.wcc.ne.gov/ Applicant’s Name: Social Security Number: Address: City or Town: State: Zip Code: Date of Birth: Business Telephone: EDUCATION AND TRAINING Name & Location Dates From/To Major Degree Month/Year of Degree College/University: Medical School: Osteopathic School: Chiropractic School: Other: PROFESSION Specialty: Subspecialty: Board certification with: Board certification with: Certification expires: _____________ Certification expires: _____________ Have you ever performed an independent medical exam? Yes No If yes, how many years have you been performing IMEs? _____________ What percentage of current practice is IMEs? List any IME training you have attended: Please list any experience or education concerning workers’ compensation principles or the Nebraska workers’ compensation system: Please identify any employer, insurer, attorney, employee group, managed care plan or representatives of any of these to whom you are under contract or who regularly use your services: If appointed, what type of cases would you prefer be referred to you? NWCC Form 62 (03/2009) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Independent Medical Examiner — Application For Appointment Nebraska State License # Are you currently licensed in any other state? Tax I.D. # Yes No Drug Enforcement Agency # If yes, please list state and license #: List any other registrations, certifications or licenses you possess: Have you ever been subject to disciplinary action? Have you ever voluntarily surrendered your license? Yes Yes No No If yes, please explain: If yes, please explain: PRACTICE HISTORY Present practice name and location: Name: Type of Practice: From: __________ Address: List other site addresses if applicable: Prior practice name(s) and location(s): 1. Name: Address: City, State & Postal Code: 2. Telephone: From: __________ Name: Address: Telephone: City, State & Postal Code: 3. To: __________ From: __________ To: __________ Name: Address: Telephone: City, State & Postal Code: From: __________ To: __________ I request appointment to the list of independent medical examiners maintained by the Nebraska Workers’ Compensation Court. I will provide independent, impartial and objective medical findings in all cases that come before me. I will decline a request to serve as an independent medical examiner only for good cause shown. If I determine an examination is necessary, I will contact the employee within 10 business days after receipt of records from all parties to schedule an appointment. I will submit a written report within 10 business days following receipt of all necessary records and information, the completion of an examination, or the completion of any required tests, whichever is applicable. I will accept the fees established pursuant to Rule 65 as payment in full for services rendered as an independent medical examiner. I will submit to a review pursuant to Rule 62, E. I have read and understand Rule 62 though Rule 66 of the Nebraska Workers’ Compensation Court, which describe the independent medical examiner system. I agree to comply with all of the provisions of these rules. I hereby attest that the information contained in this application is correct to the best of my knowledge and belief. I understand that false or misleading information may result in the rejection of my application or in my removal from the list if I am appointed. SIGNATURE NWCC Form 62 (03/2009) DATE Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com