DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 NYC (800)877-1373/Hemp.(866)805-3630/Haup.(866)681-5354/Peek.(866)746-0552 100 Broadway State Office Building Menands 44 Hawley Street ALBANY 12241 BINGHAMTON 13901 (866) 750-5157 (866) 802-3604 295 Main Street 6XLWH  BUFFALO 1420 (866) 211-0645 130 Main Street W. 935 James St. ROCHESTER 14614 SYRACUSE 13203 (866) 211-0644 (866) 802-3730 State of New York WORKERS' COMPENSATION BOARD PRACTITIONER'S REPORT OF REQUEST FOR INFORMATION/RESPONSE TO REQUEST REGARDING INDEPENDENT MEDICAL EXAMINATION 1. PRACTITIONER'S NAME AND ADDRESS 3. PRACTITIONER'S IME AUTHORIZATION NO. 6. CLAIMANT'S NAME 2. NAME AND ADDRESS OF PARTY REQUESTING INFORMATION 4. IME ENTITY REGISTRATION NO. (If Applicable) 7. CLAIMANT'S WCB CASE NO. 5. DATE OF INDEPENDENT MEDICAL EXAMINATION 8. DATE OF INJURY 9. DATE OF THIS REPORT Pursuant to Section 137 of the Workers' Compensation Law (WCL), if a practitioner who has performed or will be performing an independent medical examination of a workers' compensation claimant receives a request for information regarding the claimant, including faxed or electronically-transmitted requests, the practitioner must submit a copy of the request for information to the Workers' Compensation Board within ten days of the receipt of the request. In addition, copies of all responses to such requests, including all materials which are not already part of the official case record, shall be submitted by the responding practitioner to the Board within ten days of the submission of the response to the requester. PLEASE NOTE: The Board does not require that the practitioner submit reports which have already been provided to the Board and made a part of the official case record. If the practitioner receives documents in conjunction with a request for information which are already part of the Board's official case record, simply listing such documents will be sufficient to satisfy WCL Section 137. Any documents sent to the practitioner with a request for information that are not already part of the Board file must be submitted to the Board. If the request for information is limited to a request for scheduling of an independent medical examination, you need not file this form. However, you must send a copy of Form IME-5 ("Claimant's Notice of Independent Medical Examination") to the designated Workers' Compensation Board office. Instructions: a. Complete all identifying information, items 1-9 above. b. To report a request for information, complete item 10-A below, sign, date and mail to appropriate Workers' Compensation Board district office within ten days of receipt of request. A copy of the request must be attached. c. To report practitioner's response to a request for information, complete item 10-B below, sign, date and mail to appropriate Workers' Compensation Board district office within ten days of submission of response to the requester. A copy of the response and all materials sent to the requester which are not already part of the official case record must be attached. d. If the practitioner responds to the requester within ten days of the receipt of the request, complete, sign and date items 10-A and 10-B and mail to the appropriate Workers' Compensation Board district office within ten days of receipt of the request, with copies of the request and response attached. Otherwise, submit separate forms to report request and your response within the time limits given in b. and c. above. NOTE: The practitioner's release of medical and/or workers' compensation records to the Board and/or to the requesting party is subject to applicable laws regarding the confidentiality of such records, including but not limited to Section 110-a of the Workers' Compensation Law, Section 18 of the Public Health Law, and other applicable state and federal laws. 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. PRACTITIONERS WHO FAIL TO FILE REQUIRED FORMS MAY BE SUBJECT TO DISCIPLINE, INCLUDING REMOVAL OF AUTHORIZATION TO PERFORM INDEPENDENT MEDICAL EXAMINATIONS. 10-A. PRACTITIONER'S REPORT OF REQUEST FOR INFORMATION REGARDING INDEPENDENT MEDICAL EXAMINATION Date request received ____________________________________________________ Attached is a copy of a request for information received in the case identified above. _______________________________________ __________________________________ _______________________ Practitioner's Name Signature Date 10-B. PRACTITIONER'S REPORT OF RESPONSE TO REQUEST FOR INFORMATION REGARDING INDEPENDENT MEDICAL EXAMINATION Date response submitted to requester ________________________________________ Attached is a copy of my response to a request for information received in the case identified above, and all materials supplied to the requester which are not already part of the official case record. _______________________________________ ___________________________________ _______________________ Practitioner's Name Date Signature IME-3 () American LegalNet, Inc. www.FormsWorkFlow.com www.wcb.state.ny.us