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Application For Independent Medical Exam-Medical Service Provider Authorization Form. This is a Oregon form and can be use in Medical Workers Comp.
Tags: Application For Independent Medical Exam-Medical Service Provider Authorization, 3930, Oregon Workers Comp, Medical
Application for Independent Medical Exam Medical Service Provider Authorization Workers’ Compensation Division Please print Medical specialty: Name: Chiropractic (M.I.) Physical work location: (City) (State) (ZIP) Mailing address, if different: (City) (State) (ZIP) General surgery Otolaryngology Physiatry Internal medicine Physical medicine Neurology Plastic surgery Neurosurgery (First) Orthopedic surgery Cardiologist (Last) Psychiatry Occupational medicine Psychology Other (specify) Phone: (Work) (Contact number, if different) Subspecialties (list): E-mail: Licensing board: Medical license number: Type of exam you are willing to perform: (See back of form for descriptions.) Independent medical examination (IME) Worker-requested medical examination (WRME) Both Will you use an IME company to schedule? If so, list IME companies: Check the geographical areas where you are willing to perform exams: (See back of form for area descriptions.) Portland Metro Eugene Metro Mid-Oregon Coast Columbia Gorge Central Oregon Salem Metro Northern Oregon Coast Southern Oregon Coast Northeastern Oregon Southern Oregon Other: (Please specify) Please provide the following: I have attended an approved IME/WRME training. I have viewed an approved IME/WRME DVD. Please provide the date and the name of the vendor. We will verify your attendance and process your application. (Date) (Vendor name) By my signature, I certify that all answers and statements on this application are true and complete to the best of my knowledge. I agree to abide by the standards of professional conduct for IMEs/WRMEs adopted by my licensing board or, if my licensing board has not adopted standards, the examination standards published in Oregon Administrative Rule (OAR) 436-010-0265 Appendix C and reprinted on the back of this form, and all relevant Oregon workers’ compensation laws and rules. I will provide independent, objective, and timely medical opinions for all exams I conduct. I understand approval of my application places me on the list of providers authorized to perform IMEs/WRMEs. I also understand that approval of my application does not guarantee me any work. Signature: Date: For assistance with this form, please contact the Medical Section at 503-934-6049. Send this completed form to: Workers’ Compensation Division Medical Section P.O. Box 14480 Salem, OR 97309-0405 Keep a copy of this form for your records. 440-3930 (5/10/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com Independent medical examination (IME): A medical examination of an injured worker by a physician other than the worker’s attending physician performed at the request of the insurer. This includes physical capacity evaluations and work capacity evaluations, if requested by the insurer. The insurer or selfinsured employer pays for this examination. Worker-requested medical exam (WRME): An impartial examination available to an injured worker when an insurer has issued a denial of compensability claim based on an independent medical exam and the injured worker’s physician does not concur with the findings (ORS 656.325). Geographic areas Portland Metro includes: Portland, Beaverton, Clackamas, Gladstone, Gresham, Hillsboro, Lake Oswego, Milwaukie, Oregon City, Scappoose, St. Helens, Tigard, Troutdale, Tualatin, West Linn Salem Metro includes: Salem/Keizer, Albany, Corvallis, Dallas, McMinnville, Monmouth/Independence, Stayton, Sublimity, Willamina, Woodburn Eugene Metro includes: Eugene, Cottage Grove, Roseburg, Springfield Northern Oregon Coast includes: Astoria, Nehalem, Tillamook, Warrenton The standards of professional conduct for performing IMEs adopted by the relevant health professional regulatory board, if any, apply. If the health professional regulatory board does not adopt standards, the Independent Medical Examination Standards published as Appendix C in OAR 436-010-0265 apply. IME standards 1. 2. 3. 4. 5. Mid-Oregon Coast includes: Lincoln City, Newport, Toledo Southern Oregon Coast includes: Bandon, Brookings, Coos Bay/North Bend, Coquille, Florence, Gold Beach, Port Orford, Reedsport Columbia Gorge includes: Boardman, Cascade Locks, Hood River, The Dalles Northeastern Oregon includes: Baker City, Hermiston, LaGrande, Milton-Freewater, Ontario, Pendleton, Umatilla, Vale Central Oregon includes: Bend, Madras, Prineville, Redmond, Sisters Southern Oregon includes: Ashland, Central Point, Grants Pass, Klamath Falls, Medford 6. Other includes: Any location not described above 7. 8. 9. Communicate honestly with the parties involved in the examination. Conduct the examination with dignity and respect for the parties involved. Identify yourself to the examinee as an independent examining physician. Verify the examinee’s identity. Discuss the following with the examinee before beginning the examination: a. Remind the examinee of the party who requested the examination. b. Explain to the examinee that a physician-patient relationship will not be sought or established. c. Tell the examinee the information provided during the examination will be documented in a report. d. Review the procedures that will be used during the examination. e. Advise the examinee a procedure may be terminated if the examinee feels the activity is beyond the examinee’s physical capacities or when pain occurs. f. Answer the examinee’s questions about the examination process. During the examination: a. Ensure the examinee has privacy to disrobe. b. Avoid personal opinions or disparaging comments about the parties involved in the examination. c. Examine the condition being evaluated sufficient to answer the requesting party’s questions. d. Let the examinee know when the examination has concluded, and ask if the examinee has questions or wants to provide additional information. Provide the requesting party a timely report that contains findings of fact and conclusions based on medical probabilities for which the physician is qualified to express an opinion. Maintain the confidentiality of the parties involved in the examination subject to applicable laws. At no time provide a favorable opinion based solely or in part upon an accepted fee for service. American LegalNet, Inc. www.FormsWorkFlow.com