Workers222 Compensation Division Insurer222s Request for Director Approval of an Additional Independent Medical Examination WORKER INFORMATION Worker name: Phone: Address: Date of injur y: Insurer: Claim no.: INDEPENDENT MEDICAL EXAMINATION (IME) INFORMATION 1. State the reasons you are requesting an additional IME and the conditions you want to have evaluated. Note: Include any medical documentation you want to have considered in this matter. (Use the back of this form or attach additional sheets , if necessary.) 2. What was the date of the last IME to evaluate this condition? Date: 3. How many IMEs has the worker attended since the claim was last opened? 4. Attach copies of previous IME notification letters for this open period. If you cannot provide copies, list all examinations in chronological order, with the names of the examiners, time, date, place, and conditions evaluated. (Use the back of this form or attach additional sheets, if necessary . ) 5. What was the purpose of the previous IMEs? CERTIFICATION STATEMENT By signing below, I certify that I: Have answered all questions to the best of my ability. Have attached sufficient documentation to support the request (See Bulletin 252). Will provide a copy of this request to the worker and the worker 222s attorney (if represented). Signature: Date: Send a completed and signed copy of this form and all accompanying documents to: Workers222 Compensation Division, Medical Resolution Team 350 Winter St. NE, P.O. Box 14480 Salem, O R 97309 - 0405 NOTICE TO THE WORKER If you object to the request for an additional independent medical examination (IME), send your objections within 10 days from the date of this request to: Workers222 Compensation Division, Medical Resolution Team 350 Winter St. NE P.O. Box 14480 Salem OR 97309-0405 Otherwise, the director will approve or deny the insurer222s request based only on available information. For more information, contact the Medical Resolution Team at 503-947-7606, email wcd.medical questions@oregon.gov , or visit our w ebsite: www.wcd.oregon.gov . 440 - 2333 (3/15 /DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com