APPROVED IME EXAMINER UPDATE Dept. of Labor and Industries Provider Review & Education PO Box 44322 Olympia WA 98504-4322 (360) 902-6815 FAX (360) 902-4249 CONTACT INFORMATION Conduct examinations for: Please type or print State Fund Self Insured Crime Victims Compensation Examiner name (Last, First, MI) National Provider Number (optional) Examiner mailing address Phone number City State ZIP + 4 Do you have internet access in your office? Yes No AVAILABILITY I am available to conduct independent medical examinations. Do not remove my name from the approved examiner list. I am temporarily unavailable to conduct independent medical examinations. Do not remove my name from the approved examiner list. I will be available to schedule appointments after ___________________________. Date I am not available to conduct independent medical examinations. Please remove my name from the approved examiner list and inactivate my IME provider number(s). I have been informed that if my name is voluntarily removed from the list I may reapply in the future. Any future application will be subject to approval criteria in use at the time of the application. QUALIFICATIONS Direct patient care status (excluding IMEs) is __________ hours per week. (circle one) Full-time Part-time (under 32 hrs/week) Limited ( less than 8 hrs/week) Practice Specialty__________________________. Retired as of ___________________ Month/Year Sub- specialty________________________. Current license held in the following state(s) _______________________________________________. Add new Board or Sub-specialty certification (provide copy) ________________________________________ Add new fellowship _______________________________________________________________________ Provide current curriculum vitae Begin date End date EXAM SITES No exam site changes. I no longer conduct exams for the following IME firm(s). Please inactivate the IME provider number(s) for:________________________________________________________________ Update exam site locations listed on the attached Exam Site page. SIGNATURE I certify the above information is accurate. I have not had any charges or actions against my license to practice or have been charged with a criminal activity or misdemeanor during the past 3 years. Date: ____________________ F245-051-000 approved ime examiner update 4-07 Signature:_________________________________________ American LegalNet, Inc. www.FormsWorkflow.com Approved IME Provider Update Instructions Complete all that apply in order to update or correct the information listed on the website at www.imes.lni.wa.gov under “Find a Medical Examiner”. At a minimum the form must contain contact information, list availability status, indicate direct patient care status and be signed and dated. Contact Information • List current mailing address and phone number where the Department may contact you directly. A post office box will be accepted in place of a street address. This information will appear on the website. • List National Provider Number (optional). • Indicate the type of IME referrals you accept from the Department. • Indicate whether or not you have internet access in your office. Availability • Indicate your availability to conduct IMEs. • Examiners who are listed as temporarily unavailable will be removed from the list after 18 months of inactivity. Your IME provider number(s) will be inactivated at that time. Reapplication will be required once an examiner has been removed. Qualifications • Enter your direct patient care status. Per WAC 296-23-317 the definition of direct patient care (DPC) excludes the hours spent conducting IMEs. At a minimum an examiner must provide an average of 8 hours per week DPC during the last two years to be considered in active practice. Examiners who meet that definition will be listed as providing full time (32 hours or more) or part time (under 32 hours) DPC on the approved examiner database. Examiners who have engaged in less than an average of 8 hours per week during the last two year period will be listed as providing limited direct patient care. Limited direct patient care is not considered active practice per WAC. • Enter practice specialty and sub-specialty. • Enter name of state(s) where you conduct IMEs. • Enter any new board or sub-specialty certifications. Provide a copy of the certificate(s). • Enter any new fellowship. Provide updated curriculum vitae listing the fellowship and dates of the program. Exam Sites • List the name of the IME firm with which you no longer maintain a business relationship to conduct IMEs. Your provider number for that firm will be inactivated. • List exam site location changes on the IME Provider Exam Site form (F245-047-000) and include it with the Update form. Signature • Date and sign the form. F245-051-000 approved examiner update 4-07 American LegalNet, Inc. www.FormsWorkflow.com