Form IME-5 "Claimant's Notice of Independent Medical Examination" - New York

What Is Form IME-5?

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-5 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-5 "Claimant's Notice of Independent Medical Examination" - New York

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State of New York
WORKERS' COMPENSATION BOARD
CLAIMANT'S NOTICE OF INDEPENDENT MEDICAL EXAMINATION
under Section 137 WCL
WCB CASE NUMBER
CARRIER CASE NUMBER
DATE OF ACCIDENT
DATE OF THIS NOTICE
CLAIMANT'S NAME AND ADDRESS
INSURANCE CARRIER'S NAME AND ADDRESS
IME ENTITY NAME
AUTHORIZATION NUMBER
DATE OF EXAMINATION
PLACE OF EXAMINATION
THIS EXAMINATION WAS REQUESTED BY
TIME OF EXAMINATION
IF THIS EXAMINATION WAS REQUESTED BY THE CLAIMANT, THE CLAIMANT MAY BE RESPONSIBLE FOR PAYMENT OF THE COST OF
THE EXAMINATION. THE COST OF THIS EXAMINATION WILL BE: (Health provider must indicate exact fee or fee range.)
Exact fee: $
Fee range: From $
To $
THE INDEPENDENT EXAMINER
INTENDS
DOES NOT INTEND
TO RECORD OR VIDEOTAPE THIS EXAMINATION.
(This notice is invalid if this item is not completed.)
Purpose of Examination/Special Instructions:
You have been scheduled for an independent medical examination in connection with your workers'
compensation claim at the time and place indicated above. YOUR RECEIPT OF BENEFITS COULD
BE DENIED, TERMINATED OR REDUCED AS A RESULT OF A DETERMINATION WHICH MAY
BE BASED ON A MEDICAL EVALUATION MADE AFTER THIS MEDICAL EXAMINATION. You
have the right to videotape or otherwise record the examination. You also have the right to be
accompanied during the exam by an individual or individuals of your choosing. See the reverse of
this form for a complete statement of your rights and obligations under the law with regard to
independent medical examinations.
If for any reason you are unable to appear for this examination, contact
Name
at
as soon as possible.
Telephone Number
IME-5 (5-18)
State of New York
WORKERS' COMPENSATION BOARD
CLAIMANT'S NOTICE OF INDEPENDENT MEDICAL EXAMINATION
under Section 137 WCL
WCB CASE NUMBER
CARRIER CASE NUMBER
DATE OF ACCIDENT
DATE OF THIS NOTICE
CLAIMANT'S NAME AND ADDRESS
INSURANCE CARRIER'S NAME AND ADDRESS
IME ENTITY NAME
AUTHORIZATION NUMBER
DATE OF EXAMINATION
PLACE OF EXAMINATION
THIS EXAMINATION WAS REQUESTED BY
TIME OF EXAMINATION
IF THIS EXAMINATION WAS REQUESTED BY THE CLAIMANT, THE CLAIMANT MAY BE RESPONSIBLE FOR PAYMENT OF THE COST OF
THE EXAMINATION. THE COST OF THIS EXAMINATION WILL BE: (Health provider must indicate exact fee or fee range.)
Exact fee: $
Fee range: From $
To $
THE INDEPENDENT EXAMINER
INTENDS
DOES NOT INTEND
TO RECORD OR VIDEOTAPE THIS EXAMINATION.
(This notice is invalid if this item is not completed.)
Purpose of Examination/Special Instructions:
You have been scheduled for an independent medical examination in connection with your workers'
compensation claim at the time and place indicated above. YOUR RECEIPT OF BENEFITS COULD
BE DENIED, TERMINATED OR REDUCED AS A RESULT OF A DETERMINATION WHICH MAY
BE BASED ON A MEDICAL EVALUATION MADE AFTER THIS MEDICAL EXAMINATION. You
have the right to videotape or otherwise record the examination. You also have the right to be
accompanied during the exam by an individual or individuals of your choosing. See the reverse of
this form for a complete statement of your rights and obligations under the law with regard to
independent medical examinations.
If for any reason you are unable to appear for this examination, contact
Name
at
as soon as possible.
Telephone Number
IME-5 (5-18)
STATEMENT OF RIGHTS AND OBLIGATIONS - INDEPENDENT MEDICAL EXAMINATIONS - Section 137 WCL
1. The claimant must receive notice of the scheduled independent medical examination at least seven business days prior to such examination.
The notice must advise the claimant if the practitioner intends to record or videotape the examination.
2. If the examination was requested by the claimant, the claimant may be responsible for the cost of the examination, and the health provider must
indicate on the notice of examination the actual fee or the fee range for the examination.
3. All independent medical examinations shall be performed in medical facilities suitable for such exam,with due regard and respect for the privacy
and dignity of the injured worker/claimant.
4. Examination facilities must be provided in a safe, convenient and accessible location within a reasonable distance from the claimant's residence.
Examinations will be held during regular business hours, except with the consent and for the convenience of the claimant.
5. All independent medical examinations shall be performed by an independent examiner competent to evaluate or examine the injury or disease
from which the claimant suffers. An independent examiner is not eligible to perform an independent medical examination of a claimant if the
independent examiner has treated or examined the claimant for the condition for which the examination is being requested, or if another member
of the preferred provider organization or managed care provider to which the independent examiner belongs has treated or examined the
claimant for the condition for which the examination is being requested.
6. The claimant has the right to videotape or otherwise record the examination.
7. The claimant has the right to be accompanied during the examination by an individual or individuals of his/her choosing.
8. The claimant has the right to be reimbursed for travel expenses to and from the examination site, if the examination was requested by the
insurance carrier or employer.
9. A copy of each report of independent medical examination shall be submitted by the practitioner on the same day and in the same manner to
the Workers' Compensation Board, the insurance carrier, the claimant's attending physician or other attending independent examiner, the
claimant's representative, if any, and the claimant.
10. The claimant's receipt of benefits could be denied, terminated, or reduced as a result of a determination, made by the Workers' Compensation
Board, which may be based upon a medical evaluation made after an independent medical examination. However, the ability of the claimant to
appear for an examination or hearing shall not in itself determine questions of disability, extent of disability or eligibility for benefits.
11. In any open case where an award has been directed by the Board for temporary or permanent disability at an established rate of compensation,
and there is a direction by the Board for continuation of payments, or any closed case where an award for compensation has been made for
permanent total or permanent partial disability, a report of an independent medical examination shall not be the basis for suspending or reducing
payments unless and until the rules and regulations of the Board regarding suspending or reducing payments have been met and there is a
determination by the Board finding that such suspension or reduction is justified.
12. The claimant has the right to appeal any Workers' Compensation Board determination, including determinations based on an independent
medical examination. The Board's notice of decision contains full instructions and time limitations for filing an appeal.
HIPAA Notice: In order to adjudicate a workers' compensation claim, WCL Sections 13-a and 137 permit an employer or carrier to have a claimant
examined by a health care provider. Pursuant to 45 CFR 512 a health care provider who has been retained by an employer or carrier to evaluate a
workplace injury is exempt from HIPAA's restrictions on disclosure of health information.
IF YOU HAVE ANY QUESTIONS ABOUT AN INDEPENDENT MEDICAL EXAMINATION, OR ANY OTHER QUESTIONS OR PROBLEMS ABOUT
A JOB-RELATED INJURY OR DISEASE, CONTACT ANY OFFICE OF THE WORKERS' COMPENSATION BOARD.
SI TIENE ALGUNA DUDA SOBRE LAS EVALUACIONES MÉDICAS INDEPENDIENTES, O CUALQUIER OTRA PREGUNTA O PROBLEMA
SOBRE ENFERMEDADES O LESIONES RELACIONADAS CON SU TRABAJO, COMUNÍQUESE CON CUALQUIER OFICINA DE LA INSTITUCIÓN
WORKERS' COMPENSATION BOARD (JUNTA DE COMPENSACIÓN LABORAL).
NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205
Customer Service Toll-Free Line: 877-632-4996
Statewide Fax Line: 877-533-0337
IME-5 (5-18) Reverse
www.wcb.ny.gov
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