Form MR/IME-1 "Health Provider's Application for Authorization Under the Workers' Compensation Law" - New York

What Is Form MR/IME-1?

This is a legal form that was released by the New York State Workers' Compensation Board - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2018;
  • The latest edition provided by the New York State Workers' Compensation Board;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MR/IME-1 by clicking the link below or browse more documents and templates provided by the New York State Workers' Compensation Board.

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Download Form MR/IME-1 "Health Provider's Application for Authorization Under the Workers' Compensation Law" - New York

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State of New York
CHECK ONE:
CHECK ONE:
WORKERS' COMPENSATION BOARD
THIS
AGENCY
EMPLOYS
AND
SERVES
q Physician
q Initial Authorization
Medical Director's Office - Riverview Center
PEOPLE
WITH
DISABILITIES
WITHOUT
q Podiatrist
q Reinstatement
150 Broadway - Suite 195
DISCRIMINATION
q Chiropractor
q Change in Rating
Menands, NY 12204
q Psychologist
(Physician only)
1-800-781-2362
HEALTH PROVIDER'S APPLICATION FOR AUTHORIZATION UNDER THE WORKERS' COMPENSATION LAW
IMPORTANT INSTRUCTIONS TO HEALTH PROVIDERS
Complete both sides of this application. Do not fill in shaded area. All entries are to be typewritten or printed clearly. Illegible applications will be returned to the applicant.
Physicians: Submit in duplicate to your County Medical Society. Osteopathic physicians may submit to their County Medical Society or the New York State Osteopathic
Medical Society. A copy of the application (face sheet only) must be filed with the Workers' Compensation Board at the above address at the same time it is submitted to the
Medical Society.
Other Health Providers: Submit to appropriate committee (Podiatry Practice Committee, Psychology Practice Committee, or Chiropractic Practice Committee) at the above
address.
The undersigned hereby makes application to be authorized by the Chair, Workers' Compensation Board for the following: CHECK ALL THAT APPLY
To render appropriate care to persons suffering injury or illness in accordance with the Workers' Compensation Law (WCL), to volunteer firefighters in
accordance with the Volunteer Firefighters' Benefit Law (VFBL) and volunteer ambulance workers in accordance with the Volunteer Ambulance Workers' Benefit
Law (VAWBL), and requests the following rating (physicians only)___________________________________ .
To conduct independent medical examinations (IME's) of persons suffering work-related injury or illness under the WCL, VFBL and VAWBL.
1. Name_________________________________________________________________________ Date of Birth__________________________________
2. Home Address_______________________________________________________________________________________________________________
County________________________ Home Telephone No.______________________
3. NYS Professional License No. ___________________________________ Date License Granted______________________ NPI No. _______________________
4. Office Address(es): List below all of your offices of practice in New York State. Attach an additional sheet of paper if necessary. For each address listed below,
you must have a valid registration certificate from the New York State Education Department. If any of your office addresses are not currently registered, please
call the Division of Professional Licensing Services at (518) 474-3817. Be advised that any address registered with the Education Department will be given out to
claimants.
Principal Office Address ______________________________________________________________________ Office Tel. No.____________________
Street
City
County
Zip Code
Other Office Address__________________________________________________________________________Office Tel. No. ____________________
Street
County
City
Zip Code
Email: ___________________________________________________________________________________________________________
5. Major Hospital Affiliations in New York State:
A. Hospital_________________________________________________________________________ Zip Code_________________________________
Clinical Service_______________________________________ Positions Held_________________________Date____________________________
B. Hospital__________________________________________________________________________ Zip Code_________________________________
Clinical Service_______________________________________ Positions Held_________________________Date____________________________
q County Medical Society: County of ____________________________________________
6. Current Professional Society Memberships:
q American Medical Association
q Specialty Societies _________________________________________________________
q Medical Society of the State of New York
q Board Certification, American Board of Medical Specialties
q New York State Osteopathic Medical Society
q Board Certification, American Osteopathic Association
q Board Certification, Other ____________________________________________________
Physicians seeking authorization to conduct Independent Medical Examinations (IME's) must be board certified by a medical or osteopathic specialty board
that is recognized by the Workers' Compensation Board.
7. Graduate of (Professional School) ________________________________________________Degree _____________________ Year _____________
8. Post-graduate study in College or Hospital_______________________________________________________________________________________
9. All psychologists, podiatrists, chiropractors, please attach curriculum vitae including academic training, supervision and experience.
10. Have you completed an authorized or approved residency? q Yes q No
If "yes," attach a copy of the certificate of completion or a letter from a
hospital administrator confirming completion of approved residency.
11. If you have been certified by any specialty board, specify board and date of certification below and attach proof of certification:
a. ___________________________________ Date__________________
b. __________________________________ Date___________________
For Office Use Only - Do Not Fill in Shaded Area
a.
1
3
Rating(s) Given
By:______________
Status
b.
Date of Current Rating
2
4
Med. Reg. Sec.
MR/IME-1 (8-18)
Continued on Reverse
www.wcb.ny.gov
State of New York
CHECK ONE:
CHECK ONE:
WORKERS' COMPENSATION BOARD
THIS
AGENCY
EMPLOYS
AND
SERVES
q Physician
q Initial Authorization
Medical Director's Office - Riverview Center
PEOPLE
WITH
DISABILITIES
WITHOUT
q Podiatrist
q Reinstatement
150 Broadway - Suite 195
DISCRIMINATION
q Chiropractor
q Change in Rating
Menands, NY 12204
q Psychologist
(Physician only)
1-800-781-2362
HEALTH PROVIDER'S APPLICATION FOR AUTHORIZATION UNDER THE WORKERS' COMPENSATION LAW
IMPORTANT INSTRUCTIONS TO HEALTH PROVIDERS
Complete both sides of this application. Do not fill in shaded area. All entries are to be typewritten or printed clearly. Illegible applications will be returned to the applicant.
Physicians: Submit in duplicate to your County Medical Society. Osteopathic physicians may submit to their County Medical Society or the New York State Osteopathic
Medical Society. A copy of the application (face sheet only) must be filed with the Workers' Compensation Board at the above address at the same time it is submitted to the
Medical Society.
Other Health Providers: Submit to appropriate committee (Podiatry Practice Committee, Psychology Practice Committee, or Chiropractic Practice Committee) at the above
address.
The undersigned hereby makes application to be authorized by the Chair, Workers' Compensation Board for the following: CHECK ALL THAT APPLY
To render appropriate care to persons suffering injury or illness in accordance with the Workers' Compensation Law (WCL), to volunteer firefighters in
accordance with the Volunteer Firefighters' Benefit Law (VFBL) and volunteer ambulance workers in accordance with the Volunteer Ambulance Workers' Benefit
Law (VAWBL), and requests the following rating (physicians only)___________________________________ .
To conduct independent medical examinations (IME's) of persons suffering work-related injury or illness under the WCL, VFBL and VAWBL.
1. Name_________________________________________________________________________ Date of Birth__________________________________
2. Home Address_______________________________________________________________________________________________________________
County________________________ Home Telephone No.______________________
3. NYS Professional License No. ___________________________________ Date License Granted______________________ NPI No. _______________________
4. Office Address(es): List below all of your offices of practice in New York State. Attach an additional sheet of paper if necessary. For each address listed below,
you must have a valid registration certificate from the New York State Education Department. If any of your office addresses are not currently registered, please
call the Division of Professional Licensing Services at (518) 474-3817. Be advised that any address registered with the Education Department will be given out to
claimants.
Principal Office Address ______________________________________________________________________ Office Tel. No.____________________
Street
City
County
Zip Code
Other Office Address__________________________________________________________________________Office Tel. No. ____________________
Street
County
City
Zip Code
Email: ___________________________________________________________________________________________________________
5. Major Hospital Affiliations in New York State:
A. Hospital_________________________________________________________________________ Zip Code_________________________________
Clinical Service_______________________________________ Positions Held_________________________Date____________________________
B. Hospital__________________________________________________________________________ Zip Code_________________________________
Clinical Service_______________________________________ Positions Held_________________________Date____________________________
q County Medical Society: County of ____________________________________________
6. Current Professional Society Memberships:
q American Medical Association
q Specialty Societies _________________________________________________________
q Medical Society of the State of New York
q Board Certification, American Board of Medical Specialties
q New York State Osteopathic Medical Society
q Board Certification, American Osteopathic Association
q Board Certification, Other ____________________________________________________
Physicians seeking authorization to conduct Independent Medical Examinations (IME's) must be board certified by a medical or osteopathic specialty board
that is recognized by the Workers' Compensation Board.
7. Graduate of (Professional School) ________________________________________________Degree _____________________ Year _____________
8. Post-graduate study in College or Hospital_______________________________________________________________________________________
9. All psychologists, podiatrists, chiropractors, please attach curriculum vitae including academic training, supervision and experience.
10. Have you completed an authorized or approved residency? q Yes q No
If "yes," attach a copy of the certificate of completion or a letter from a
hospital administrator confirming completion of approved residency.
11. If you have been certified by any specialty board, specify board and date of certification below and attach proof of certification:
a. ___________________________________ Date__________________
b. __________________________________ Date___________________
For Office Use Only - Do Not Fill in Shaded Area
a.
1
3
Rating(s) Given
By:______________
Status
b.
Date of Current Rating
2
4
Med. Reg. Sec.
MR/IME-1 (8-18)
Continued on Reverse
www.wcb.ny.gov
12. Are you employed by any health provider, organization, commercial firm, union or hospital to render care or conduct independent medical examinations?
q Yes q No
If "Yes," explain________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
13. Are you presently, or were you previously, authorized to (a) render care under the Workers' Compensation Law? q Yes q No
If "Yes", give date and
q Yes q No
authorization number:______________________________
(b) conduct independent medical examinations?
If "Yes", give date and
authorization number:_____________________________
14. Have you ever previously applied for authorization to render care or conduct independent medical examinations under the Workers' Compensation Law,
which application was not granted? q Yes q No
15. Was your name ever removed (voluntarily or otherwise) from a list of health providers authorized to render care or conduct independent medical
examinations under the Workers' Compensation Law of any state or under any Federal program? q Yes
q No
If "Yes," give state or program
involved and explain reason for removal:______________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
If your authorization was reinstated, give date of reinstatement ___________________________________________________________________________
16. Have you ever had a professional license suspended or revoked? q Yes
q No
If "Yes," give state or jurisdiction and explain reason:_____________
_______________________________________________________________________________________________________________________________
17. Have you ever had restrictions or limitations placed on a professional license? q Yes
q No
If "Yes," give state or jurisdiction and explain reason:___
________________________________________________________________________________________________________________________________
18. Can you accommodate claimants whose language is other than English? q Yes
q No
If "Yes," please specify: ______________________________
The applicant acknowledges that any authorization granted by the Chair is conditioned upon compliance with the Workers' Compensation Law
and Board Rules, including but not limited to the following:
The applicant shall submit all records and evidence needed for any investigation upon direction by the Chair, Workers' Compensation Board or the local
County Medical Society, or the New York State Osteopathic Medical Society, or the appropriate Practice Committee.
The applicant shall file timely, complete and accurate reports of treatment rendered to claimants, as required by law or regulation or directed by the Chair
or the Board, whenever applicant renders such treatment. Such reports of treatment shall be timely filed as required by the Chair or Board, and shall be
provided upon request to the employer or employer's insurance carrier. The applicant shall transmit copies of medical reports to claimant's licensed
representative or attorney upon receipt of a written request or consent signed by the claimant and accompanied by a notice of retainer, where applicant is
acting as claimant's attending physician or medical consultant.
The applicant shall submit a signed, certified copy of each report of an independent medical examination on the same day and in the same manner to the
Board, the insurance carrier, the claimant's attending physician or other attending practitioner, the claimant's representative and the claimant.
If
authorized to conduct independent medical examinations, the applicant further agrees to provide such reports and submit to such investigation as may be
required by the Chair.
The applicant shall not undertake or continue the care, or conduct an independent medical examination, of a claimant whose condition requires a
professional service for which he/she is not qualified and authorized by the Chair, Workers' Compensation Board, or which is outside the limits prescribed
by the New York State Education Law for podiatrists, chiropractors, or psychologists, as the case may be. In the event that a case develops a
complication beyond applicant's qualification and authorization, applicant shall promptly refer such case for consultation and/or to the service of a health
provider qualified and authorized to render the needed care or conduct the independent medical examination.
The applicant shall appear before the Board or answer upon request of the Chair, the Board, a Workers' Compensation Law Judge, the appropriate
Practice Committee (if applicable), or any duly authorized officer of the State, any questions in connection with a workers' compensation, volunteer
firefighter or volunteer ambulance worker claim.
The applicant shall refrain from treating subsequently for remuneration, as a private patient, any person seeking medical treatment or submitting to an
independent medical examination in connection with, or as a result of, any injury covered under the Workers' Compensation Law, the Volunteer
Firefighters' Benefit Law, or the Volunteer Ambulance Workers' Benefit Law, if he/she has been removed from the list of health providers authorized to
render such medical care or to conduct such independent medical examination or if the person seeking treatment has been transferred from his/her care
in accordance with the law.
The applicant further shall abide by the provisions of the Workers' Compensation Law and the Rules adopted thereunder.
The undersigned applicant affirms that the foregoing answers are true to the best of his/her knowledge and belief and agrees that if he/she has made any
materially false statement in this application, any authorization granted as a result of this application may be revoked pursuant to the provisions of the Workers'
Compensation Law.
Signature of Applicant___________________________________________________________________ Date__________________________________
APPLICATION RECOMMENDED:
Treatment - Rating Recommended_______________
IME
Physicians only
APPLICATION NOT RECOMMENDED
By: q Medical Society of the County of _______________________________ q New York State Osteopathic Medical Society
q Podiatry Practice Committee
q Chiropractic Practice Committee
q Psychology Practice Committee
Medical Society
or Practice Committee Chair________________________________________ _______________________________________ ____________________
Signature
Date
Typed or Printed Name
Practice Committee Member________________________________________ _______________________________________ ____________________
Date
Signature
Typed or Printed Name
Practice Committee Member________________________________________ _______________________________________ ____________________
Typed or Printed Name
Signature
Date
MR/IME-1 Reverse (8-18)
Page of 2