State of New York WORKERS' COMPENSATION BOARDCLAIMANT'S NOTICE OF INDEPENDENT MEDICAL EXAMINATION under Section 137 WCLIME-5 (5-18) You have been scheduled for an independent medical examination in connection with your workers' compensation claim at the time and place indicated above. YOUR RECEIPT OF BENEFITS COULD BE DENIED, TERMINATED OR REDUCED AS A RESULT OF A DETERMINATION WHICH MAY BE BASED ON A MEDICAL EVALUATION MADE AFTER THIS MEDICAL EXAMINATION. You have the right to videotape or otherwise record the examination. You also have the right to be accompanied during the exam by an individual or individuals of your choosing. See the reverse of this form for a complete statement of your rights and obligations under the law with regard to independent medical examinations.If for any reason you are unable to appear for this examination, contactatas soon as possible. CLAIMANT'S NAME AND ADDRESS INSURANCE CARRIER'S NAME AND ADDRESS WCB CASE NUMBER CARRIER CASE NUMBER DATE OF ACCIDENT DATE OF THIS NOTICE IME ENTITY NAME AUTHORIZATION NUMBER DATE OF EXAMINATION TIME OF EXAMINATION PLACE OF EXAMINATION THIS EXAMINATION WAS REQUESTED BY Purpose of Examination/Special Instructions: IF THIS EXAMINATION WAS REQUESTED BY THE CLAIMANT, THE CLAIMANT MAY BE RESPONSIBLE FOR PAYMENT OF THE COST OF THE EXAMINATION. THE COST OF THIS EXAMINATION WILL BE: (Health provider must indicate exact fee or fee range.) THE INDEPENDENT EXAMINERINTENDSDOES NOT INTEND TO RECORD OR VIDEOTAPE THIS EXAMINATION.(This notice is invalid if this item is not completed.) Exact fee: $ Fee range: From $ To $ Name Telephone Number IME-5 (5-18) ReverseSTATEMENT OF RIGHTS AND OBLIGATIONS - INDEPENDENT MEDICAL EXAMINATIONS - Section 137 WCL1.The claimant must receive notice of the scheduled independent medical examination at least seven business days prior to such examination.The notice must advise the claimant if the practitioner intends to record or videotape the examination.2.If the examination was requested by the claimant, the claimant may be responsible for the cost of the examination, and the health provider mustindicate on the notice of examination the actual fee or the fee range for the examination.3.All independent medical examinations shall be performed in medical facilities suitable for such exam,with due regard and respect for the privacyand dignity of the injured worker/claimant.4.Examination facilities must be provided in a safe, convenient and accessible location within a reasonable distance from the claimant's residence.Examinations will be held during regular business hours, except with the consent and for the convenience of the claimant.5.All independent medical examinations shall be performed by an independent examiner competent to evaluate or examine the injury or diseasefrom which the claimant suffers. An independent examiner is not eligible to perform an independent medical examination of a claimant if theindependent examiner has treated or examined the claimant for the condition for which the examination is being requested, or if another memberof the preferred provider organization or managed care provider to which the independent examiner belongs has treated or examined theclaimant for the condition for which the examination is being requested.6.The claimant has the right to videotape or otherwise record the examination.7.The claimant has the right to be accompanied during the examination by an individual or individuals of his/her choosing.8.The claimant has the right to be reimbursed for travel expenses to and from the examination site, if the examination was requested by theinsurance carrier or employer.9.A copy of each report of independent medical examination shall be submitted by the practitioner on the same day and in the same manner tothe Workers' Compensation Board, the insurance carrier, the claimant's attending physician or other attending independent examiner, theclaimant's representative, if any, and the claimant.10.The claimant's receipt of benefits could be denied, terminated, or reduced as a result of a determination, made by the Workers' CompensationBoard, which may be based upon a medical evaluation made after an independent medical examination. However, the ability of the claimant toappear for an examination or hearing shall not in itself determine questions of disability, extent of disability or eligibility for benefits.11.In any open case where an award has been directed by the Board for temporary or permanent disability at an established rate of compensation,and there is a direction by the Board for continuation of payments, or any closed case where an award for compensation has been made forpermanent total or permanent partial disability, a report of an independent medical examination shall not be the basis for suspending or reducingpayments unless and until the rules and regulations of the Board regarding suspending or reducing payments have been met and there is adetermination by the Board finding that such suspension or reduction is justified.12.The claimant has the right to appeal any Workers' Compensation Board determination, including determinations based on an independentmedical examination. The Board's notice of decision contains full instructions and time limitations for filing an appeal.IF YOU HAVE ANY QUESTIONS ABOUT AN INDEPENDENT MEDICAL EXAMINATION, OR ANY OTHER QUESTIONS OR PROBLEMS ABOUT A JOB-RELATED INJURY OR DISEASE, CONTACT ANY OFFICE OF THE WORKERS' COMPENSATION BOARD.www.wcb.ny.gov 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.SI TIENE ALGUNA DUDA SOBRE LAS EVALUACIONES M311DICAS INDEPENDIENTES, O CUALQUIER OTRA PREGUNTA O PROBLEMA SOBRE ENFERMEDADES O LESIONES RELACIONADAS CON SU TRABAJO, COMUN315QUESE CON CUALQUIER OFICINA DE LA INSTITUCI323N WORKERS' COMPENSATION BOARD (JUNTA DE COMPENSACI323N LABORAL). NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205 Customer Service Toll-Free Line: 877-632-4996 Statewide Fax Line: 877-533-0337