STATE OF NEW YORK - WORKERS' COMPENSATION BOARD PRACTITIONER'S REPORT OF INDEPENDENT MEDICAL EXAMINATION A copy of each report of Independent Medical Examination shall be submitted on the same day and in the same manner to the Workers' Compensation Board, the insurance carrier or self-insured employer, the claimant's attending physician or other attending practitioner, the claimant's representative, if any, and the claimant. CHECK ONE: PHYSICIAN PODIATRIST THIS EXAMINATION WAS REQUESTED BY: WCB CASE NO. INJURED PERSON (First Name) CARRIER CASE NO. (IF KNOWN) (Middle Initial) DATE OF INJURY (Last Name) PSYCHOLOGIST CHIROPRACTOR CARRIER/EMPLOYER INJURED PERSON'S SOCIAL SECURITY NUMBER CLAIMANT DATE OF EXAMINATION ADDRESS (Include Apt. No.) EMPLOYER INSURANCE CARRIER IF EXAMINER CONDUCTED THIS EXAMINATION AS AN EMPLOYEE OF AN IME COMPANY, OR UNDER CONTRACT OR ARRANGEMENT WITH AN IME COMPANY, STATE NAME AND WORKERS' COMPENSATION BOARD REGISTRATION NUMBER OF IME COMPANY. Results of Examination (continue on reverse or attach additional sheets, if necessary) I hereby certify that this report is a full and truthful representation of my professional opinion with respect to the claimant's condition. ________________________________________________ __________________________________________________ ____________________________ Practitioner's Name Practitioner's Signature Date ____________________________________________________________________________________ Practitioner's Address ________________________________________ IME Authorization No. NO PRACTITIONER EXAMINING OR EVALUATING A CLAIMANT UNDER THE WORKERS' COMPENSATION LAW NOR ANY SUPERVISING AUTHORITY OR PROPRIETOR NOR INSURANCE CARRIER OR EMPLOYER MAY CAUSE, DIRECT OR ENCOURAGE A REPORT TO BE SUBMITTED AS EVIDENCE IN WORKERS` COMPENSATION CLAIM ADJUDICATION WHICH DIFFERS SUBSTANTIALLY FROM THE PROFESSIONAL OPINION OF THE EXAMINING PRACTITIONER. SUCH AN ACTION SHALL BE CONSIDERED WITHIN THE JURISDICTION OF THE WORKERS` COMPENSATION FRAUD INSPECTOR GENERAL AND MAY BE REFERRED AS A FRAUDULENT PRACTICE. IME-4 (1-11) American LegalNet, Inc. www.FormsWorkFlow.com Results of Examination (continued) It is unlawful for any person who has obtained individually identifiable information from Workers' Compensation Board records to disclose such information to any person who is not otherwise lawfully entitled to obtain these records. Any person who knowingly and willfully obtains workers' compensation records which contain individually identifiable information under false pretenses or otherwise violates Workers' Compensation Law Section 110-a shall be guilty of a class A misdemeanor and shall be subject upon conviction, to a fine of not more than one thousand dollars. 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. WORKERS' COMPENSATION BOARD DISTRICT OFFICES www.wcb.state.ny.us ALBANY 12241 - 100 Broadway, Menands. (866) 750-5157 For all accidents in following counties: Albany, Clinton, Columbia, Dutchess, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington. BINGHAMTON 13901 - State Office Building, 44 Hawley Street. (866) 802-3604 For all accidents in following counties: Broome, Chemung, Chenango, Cortland, Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins. BUFFALO 14203 - 295 Main Street, Suite 400. (866) 211-0645 For all accidents in following counties: Cattaraugus, Chautauqua, Erie, Niagara. ROCHESTER 14614 - 130 Main Street West. (866) 211-0644 For all accidents in following counties: Allegany, Genesee, Livingston, Monroe, Ontario, Orleans, Seneca, Steuben, Wayne, Wyoming, Yates. SYRACUSE 13203 - 935 James Street. (866) 802-3730 For all accidents in following counties: Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence. DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill district offices) - PO Box 5205, Binghamton, NY 13902-5205. NYC (800) 877-1373 Hemp. (866) 805-3630 Haup. (866) 681-5354 Peek. (866) 746-0552 For all accidents in following counties: Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Westchester. Statewide Fax Line: 877-533-0337 IME-4 Reverse (1-11) THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION American LegalNet, Inc. www.FormsWorkFlow.com