REQUEST FOR APPOINTMENT OF INDEPENDENT MEDICAL EXAMINER, REHABILITATION EVALUATOR, OR MEDICAL CASE MANAGER WCC FILE NO. Claimant’s Social Security No. (LAST 4 DIGITS ONLY) XXX-XX-___________________ THIS SPACE FOR COURT USE ONLY: IME Physician Rehabilitation Evaluator Revised 9/7/11 Medical Case Manager Full Name of Claimant (Injured Employee) BODY PARTS Claimant’s Mailing Address Name of Respondent (Employer) City State Zip Code Name of Insurer Claimant’s Date of Birth Claimant’s Telephone Number ( ) IME Requested By: Claimant Respondent Court on its own motion Mutual Agreement Date of Injury IME Physician Selected By: Parties Court Issues: 1.____ Is the claimant currently temporarily totally disabled? 2.____Was claimant temporarily totally disabled from ____________________ to ___________________? 3.____Is claimant in need of additional medical treatment? Treatment is not authorized. 4.____Physician is requested to make specific recommendations regarding treatment. 5.____Does claimant need pain management? 6.____Per 85 O.S., §326(H), the physician is to determine the nature and extent, if any, of continuing medical maintenance. 7.____Per 85 O.S., §332(B), in relation to an objection to termination of temporary total disability, is the claimant in need of further medical treatment? Physician is to make specific recommendations regarding the reasonableness and necessity of further medical treatment. Treatment is not authorized unless agreed upon by the parties. 8.____Per 85 O.S., §329(B), the physician is to determine the reasonableness and necessity of surgery recommended by the treating physician. 9.____Physician is to render an opinion per 85 O.S., §326(G) on whether or not medical treatment provided according to either the Work Loss Data Institute’s Official Disability Guidelines (ODG) or the Oklahoma Treatment Guidelines (OTG), as applicable, is in the best interests of the employee. 10.____Diagnostic testing that is reasonable and necessary to respond to the issues specified in this order is authorized. 11.____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. 12.____Physician is requested to determine causation of claimant’s complaints. If determined to be work-related, then: (identify issues) ________________________________________________________________________________. 13.____Physician is requested to address the issue of apportionment, if applicable. 14.____Physician to determine if the claimant has suffered a change of condition for the worse. 15.____Physician to determine if the claimant is permanently and totally disabled. 16.____Physician is directed to review a videotape 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: (identify issues)__________________________________________________________________________ _____________________________________________________________________________________________. 17.____Physician to determine if the claimant is permanently and totally disabled as a result of the combination of injuries. 18.____Physician to address if vocational rehabilitation is indicated (i.e. whether as a result of the injury the claimant is unable to perform the same occupational duties the claimant was performing before the injury). 19.____Counselor is to perform rehabilitation evaluation, including recommendation for vocational retraining plans, if appropriate. 20.____Counselor is to determine transferable skills. 21.____Counselor is to provide job placement assistance. Special Instructions: Claimant’s Attorney, if represented OBA# Judge Respondent’s Attorney OBA# Date American LegalNet, Inc. www.FormsWorkFlow.com