Form IME-4.3A "Attachment for Report of Independent Medical Examination Scheduled Loss of Use" - New York

What Is Form IME-4.3A?

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 May 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 IME-4.3A 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 IME-4.3A "Attachment for Report of Independent Medical Examination Scheduled Loss of Use" - New York

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PO Box 5205
Customer Service Toll-Free Line: (877) 632-4996
Binghamton, NY 13902-5205
Statewide Fax Line: (877) 533-0337
www.wcb.ny.gov
A. Permanent Partial Disability
ATTACHMENT FOR REPORT OF INDEPENDENT
If the claimant has a permanent partial impairment,
complete A1
for all body parts and conditions for
MEDICAL EXAMINATION SCHEDULED LOSS OF USE
which a schedule award is appropriate (schedule loss of use). Use Form IME-4.3B for all body parts and
.
conditions for which a non-schedule award (classification) is appropriate
Please utilize this form as an attachment to the IME report, where there is an injury to a
A1. Schedule Loss of Use of Member:
scheduled body part. These attachments will be considered part of the IME report, and
must be served together with the IME-4.
Body Part
Please include all the information in the bullet points below in the table on this page or attach a medical
narrative with your report. The medical narrative should include the following information:
Claimant's Name
:
(LAST, FIRST, MI)
Affected body part (include left or right side) and identify Guideline chapter (when special consideration
l
Social Security No.:
exist).
Measured Active Range of Motion (ROM) (3 measurements for injured body part, and use the greatest
l
WCB Case No.:
ROM. If not, please explain why.
Measurement of contralateral body part ROM, or explain why inapplicable
l
Date of Injury/Illness:
Previously received scheduled losses of use to same body part(s), if known
l
Date of Examination:
Special considerations
l
Loading for Digits and Toes
l
Body Part/Measurement
Body Part/Measurement
Body Part/Measurement
Body Part/Measurement
Body Part/Measurement
Body Part/Measurement
1
2
3
4
5
6
Left
Right
Left
Right
Left
Right
Left
Right
Left
Right
Left
Right
Range of Motion
(3 measures)
Contralateral ROM
Contralateral
Applicable Y/N
If No, please
explain below
Special Considerations
(Chapter)
Impairment %
Details:
IME-4.3A (5-18) Page 1
PO Box 5205
Customer Service Toll-Free Line: (877) 632-4996
Binghamton, NY 13902-5205
Statewide Fax Line: (877) 533-0337
www.wcb.ny.gov
A. Permanent Partial Disability
ATTACHMENT FOR REPORT OF INDEPENDENT
If the claimant has a permanent partial impairment,
complete A1
for all body parts and conditions for
MEDICAL EXAMINATION SCHEDULED LOSS OF USE
which a schedule award is appropriate (schedule loss of use). Use Form IME-4.3B for all body parts and
.
conditions for which a non-schedule award (classification) is appropriate
Please utilize this form as an attachment to the IME report, where there is an injury to a
A1. Schedule Loss of Use of Member:
scheduled body part. These attachments will be considered part of the IME report, and
must be served together with the IME-4.
Body Part
Please include all the information in the bullet points below in the table on this page or attach a medical
narrative with your report. The medical narrative should include the following information:
Claimant's Name
:
(LAST, FIRST, MI)
Affected body part (include left or right side) and identify Guideline chapter (when special consideration
l
Social Security No.:
exist).
Measured Active Range of Motion (ROM) (3 measurements for injured body part, and use the greatest
l
WCB Case No.:
ROM. If not, please explain why.
Measurement of contralateral body part ROM, or explain why inapplicable
l
Date of Injury/Illness:
Previously received scheduled losses of use to same body part(s), if known
l
Date of Examination:
Special considerations
l
Loading for Digits and Toes
l
Body Part/Measurement
Body Part/Measurement
Body Part/Measurement
Body Part/Measurement
Body Part/Measurement
Body Part/Measurement
1
2
3
4
5
6
Left
Right
Left
Right
Left
Right
Left
Right
Left
Right
Left
Right
Range of Motion
(3 measures)
Contralateral ROM
Contralateral
Applicable Y/N
If No, please
explain below
Special Considerations
(Chapter)
Impairment %
Details:
IME-4.3A (5-18) Page 1