Department of Labor and Industries Provider Credentialing and Compliance PO Box 44322 Olympia WA 98504-4322 Phone: 360-902-6815 Fax: 360-902-4249 Approved IME Examiner Update National Provider Number (Required) Contact Information Examiner Name (Last, First, MI) Updated Contact Information: Examiner Mailing Address (Required) City State Change of Mailing Address Zip Code Change Phone Number Phone Number (Required) Email Address Availability I conduct examinations for: State Fund Self-Insured Crime Victims Compensation 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 me 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 application. I no longer conduct exams for the following IME firm(s). Please inactivate the IME provider number(s) for: ____________________________________________________________________________________ Qualifications Please provide a current curriculum vitae and copies of any new board certifications. Direct patient care status (excluding IMEs) is __________________________________ hours per week. Full time (32+ hrs/wk) Part-time (8 ­ 31 hrs/wk) Limited (less than 8 hrs/wk) Name of clinic and effective date: Contact name and phone number: Practice Specialty: Sub-specialty: Current license held in the following state(s): Add new Sub-specialty Board certification: Add new fellowship (include start/end date): I am retired as of Month/Year Signature I certify the above information is accurate. I have not had any change or actions that may affect my status as an IME examiner since I last signed the IME attestation questionnaire. (The IME Attestation Questionnaire is the required form included with all initial and renewal applications.) Signature Date American LegalNet, Inc. www.FormsWorkFlow.com F245-051-000 Approved IME Examiner Update 11-2014 Approved IME Provider Update Instructions The information on this form is used to update or correct the information listed on the website at www.imes.Lni.wa.gov under "Find a Medical Examiner." Please ensure all information is current and correct. 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 for external customers. · · List National Provider Number (NPI). List a current phone number and email address. This information is for internal use only and is not shared with external customers. Availability: · Indicate the type of IME referral you will accept from the Department. · · 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. List the name of the IME firm(s) with which you no longer maintain a business relationship to conduct IMEs. Your provider number for that firm will be inactivated. · Qualifications: · Provide updated curriculum vitae and copies of any new sub-specialties or board certifications. · Enter your direct patient care status. Per WAC 296-23-317 the definition of direct patient care (DPC) excludes the hours spent conducting IMEs. Examiners who meet that definition will be listed as providing full time (32 hours or more) or part-time (8 ­ 31 hours) DCP on the approved examiners database. Enter practice specialty and sub-specialty. Enter name of state(s) where you conduct IMEs. Provide a copy of your medical license for each state. 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 as well as a copy of your certificate of completion. · · · · Signature: · Sign and date the form. F245-051-000 Approved IME Examiner Update 11-2014 American LegalNet, Inc. www.FormsWorkFlow.com