Appointment of Independent Physician or Rehabilitation Evaluator COURT CLAIM NO. Claimant’s Social Security # Physician or Rehabilitation Evaluator Full Name of Claimant (Injured Employee) BODY PARTS FOR EXAM Claimant’s mailing address Name of Respondent (Employer) City State Claimant’s Date of Birth IME Requested By: Zip Code Claimant’s Telephone # ( ) Court on its own motion Name of Insurer Date of Injury Claimant Respondent Mutual Agreement 1. _____ Is claimant currently temporarily totally disabled? 2. _____ Was claimant temporarily totally disabled from ________________________ to ________________________ ? 3. _____ Is claimant in need of additional medical treatment? 4. _____ Does claimant need pain management? ISSUES 5. _____ By mutual stipulation of the parties, physician is authorized to treat, including referral for physical therapy per the fee schedule, if appropriate. (Treatment does NOT include surgery.) The parties waive any objection under 85 O.S. § 17(H) to the performance of said treatment and waive any objection under 85 O.S. § 14(G) to surgery if subsequently authorized. 6. _____ Physician is authorized to refer to Dr. ___________________________ for (check ONLY those applicable): EVALUATION: , TREATMENT: , of (insert body part(s) or condition(s) ________________________________________________________) 7. _____ Diagnostic testing that is reasonable and necessary to respond to the issues specified in this order is authorized. 8. _____ Surgery is authorized by mutual stipulation of the parties. The parties waive any objection under 85 O.S. § 14(G) to the performance of said surgery. 9. _____ Physician is requested to make specific recommendations regarding treatment. 10. _____ If treatment is not needed or if claimant has reached maximum medical improvement, physician is requested to rate nature and extent of permanent partial impairment, if any. 11. _____ Physician is requested to determine causation. 12. _____ Physician is requested to address the issue of apportionment, if applicable. 13. _____ Physician to determine if claimant has suffered a change of condition for the worse. 14. _____ Physician to determine if claimant is permanently and totally disabled. 15. _____ Physician may refer for a functional capacity evaluation, if appropriate. 16. _____ Physician to determine if claimant has suffered a material increase. 17. _____ Physician is directed to review (check ONLY those applicable): VIDEOTAPES(S) , [and] PHOTOGRAPHS(S) , [and] AUDIOTAPE(S) , which shall be provided by the Respondent. The cost of the physician’s review shall be borne by the Respondent in accordance with Court Rule 44. After reviewing, the physician shall address (insert issue(s) _______________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________) 18. _____ Counselor is requested to perform rehabilitation evaluation, including recommendations for vocational retraining plans, if appropriate. 19. _____ Counselor is to determine transferable skills. Special Instructions 20. _____ Counselor is to provide job placement assistance. IME Selected By: Parties Court ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ __________________________________________________ ____________________________________________________________ __________________________________________________ ____________________________________________________________ Claimant’s attorney, if represented Respondent’s Attorney OBA # OBA # Judge Date 08/02 2002 © American LegalNet, Inc.