Form IME-4 "Independent Examiner's Report of Independent Medical Examination" - New York

What Is Form IME-4?

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 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 "Independent Examiner's Report of Independent Medical Examination" - New York

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PO Box 5205
Binghamton, NY 13902-5205
Customer Service Toll-Free Line: 877-632-4996
Statewide Fax Line: 877-533-0337
www.wcb.ny.gov
COVER SHEET FOR REPORT OF INDEPENDENT MEDICAL EXAMINATION
A copy of each report of Independent Medical Examination shall be submitted on the same day and in the same manner to the Workers' Compensation Board, the
insurance carrier or self-insured employer, the claimant's attending physician or other attending independent examiner, the claimant's representative, if any, and
the claimant.
CHECK ONE:
PHYSICIAN
PODIATRIST
CHIROPRACTOR
PSYCHOLOGIST
THIS EXAMINATION WAS REQUESTED BY:
CARRIER/EMPLOYER
CLAIMANT
Injured Person's
WCB Case No.
Carrier Case No. (If Known)
Date of Injury/Illness
Date of Examination
Social Security No.
FIRST NAME
MIDDLE INITIAL
LAST NAME
ADDRESS (Include Apt. No.)
Injured Person
Insurance Carrier/
Self-Insured
Employer
Independent
Authorization No.
Date of Report of Independent Medical Examination
Examiner
Start Time of Patient Examination
End Time of Patient Examination
Total Time Spent Reviewing Records
IF EXAMINER CONDUCTED THIS EXAMINATION AS AN EMPLOYEE OF AN IME COMPANY, OR UNDER CONTRACT OR ARRANGEMENT WITH AN
IME COMPANY, STATE NAME AND WORKERS' COMPENSATION BOARD REGISTRATION NUMBER OF IME COMPANY.
Attach Report of Independent Medical Examination
Report of Independent Medical Examination must include this cover sheet and a narrative report that includes the components listed below. If
the examination concludes Schedule Loss of Use and/or Non-Schedule Permanent Partial Disability please include the IME-4.3A and/or
IME-4.3B with the cover sheet and your medical narrative.
• A description of the examination;
• A list of all documents or information reviewed by the IME evaluator;
• The examiner's professional opinion; and
• A signed and dated certification at the end of the report of the independent medical examination as follows:
• I hereby certify that this report is a full and truthful representation of my professional opinion with respect to the claimant's
condition; that no person or entity has caused, directed or encouraged me to submit a report that differs substantially from
my professional opinion; and I have reviewed the report and attest to its accuracy.
• The signature and date must be below the required certification.
Any questionnaire or intake sheets completed by the claimant either before arriving or after arriving for the independent medical examination
must be attached to this cover sheet with the report.
In certifying on the cover sheet, you are certifying to the entire contents of the Report of Independent Medical Examination.
I hereby certify that this report is a full and truthful representation of my professional opinion with respect to the claimant's
condition; that no person or entity has caused, directed or encouraged me to submit a report that differs substantially from my
professional opinion; and I have reviewed the report and attest to its accuracy.
Independent Examiner's Name
Date
Independent Examiner's Signature
IME-4 (5-18)
IME-4 5-18
PO Box 5205
Binghamton, NY 13902-5205
Customer Service Toll-Free Line: 877-632-4996
Statewide Fax Line: 877-533-0337
www.wcb.ny.gov
COVER SHEET FOR REPORT OF INDEPENDENT MEDICAL EXAMINATION
A copy of each report of Independent Medical Examination shall be submitted on the same day and in the same manner to the Workers' Compensation Board, the
insurance carrier or self-insured employer, the claimant's attending physician or other attending independent examiner, the claimant's representative, if any, and
the claimant.
CHECK ONE:
PHYSICIAN
PODIATRIST
CHIROPRACTOR
PSYCHOLOGIST
THIS EXAMINATION WAS REQUESTED BY:
CARRIER/EMPLOYER
CLAIMANT
Injured Person's
WCB Case No.
Carrier Case No. (If Known)
Date of Injury/Illness
Date of Examination
Social Security No.
FIRST NAME
MIDDLE INITIAL
LAST NAME
ADDRESS (Include Apt. No.)
Injured Person
Insurance Carrier/
Self-Insured
Employer
Independent
Authorization No.
Date of Report of Independent Medical Examination
Examiner
Start Time of Patient Examination
End Time of Patient Examination
Total Time Spent Reviewing Records
IF EXAMINER CONDUCTED THIS EXAMINATION AS AN EMPLOYEE OF AN IME COMPANY, OR UNDER CONTRACT OR ARRANGEMENT WITH AN
IME COMPANY, STATE NAME AND WORKERS' COMPENSATION BOARD REGISTRATION NUMBER OF IME COMPANY.
Attach Report of Independent Medical Examination
Report of Independent Medical Examination must include this cover sheet and a narrative report that includes the components listed below. If
the examination concludes Schedule Loss of Use and/or Non-Schedule Permanent Partial Disability please include the IME-4.3A and/or
IME-4.3B with the cover sheet and your medical narrative.
• A description of the examination;
• A list of all documents or information reviewed by the IME evaluator;
• The examiner's professional opinion; and
• A signed and dated certification at the end of the report of the independent medical examination as follows:
• I hereby certify that this report is a full and truthful representation of my professional opinion with respect to the claimant's
condition; that no person or entity has caused, directed or encouraged me to submit a report that differs substantially from
my professional opinion; and I have reviewed the report and attest to its accuracy.
• The signature and date must be below the required certification.
Any questionnaire or intake sheets completed by the claimant either before arriving or after arriving for the independent medical examination
must be attached to this cover sheet with the report.
In certifying on the cover sheet, you are certifying to the entire contents of the Report of Independent Medical Examination.
I hereby certify that this report is a full and truthful representation of my professional opinion with respect to the claimant's
condition; that no person or entity has caused, directed or encouraged me to submit a report that differs substantially from my
professional opinion; and I have reviewed the report and attest to its accuracy.
Independent Examiner's Name
Date
Independent Examiner's Signature
IME-4 (5-18)
IME-4 5-18
If the report does not substantially comply with the requirements of 12 NYCRR 300.2(d) it may be precluded from
consideration as evidence.
NO INDEPENDENT EXAMINER EXAMINING OR EVALUATING A CLAIMANT UNDER THE WORKERS' COMPENSATION LAW NOR ANY SUPERVISING
AUTHORITY OR PROPRIETOR NOR INSURANCE CARRIER OR EMPLOYER MAY CAUSE, DIRECT OR ENCOURAGE A REPORT TO BE SUBMITTED
AS EVIDENCE IN WORKERS` COMPENSATION CLAIM ADJUDICATION WHICH DIFFERS SUBSTANTIALLY FROM THE PROFESSIONAL OPINION OF
THE EXAMINING INDEPENDENT EXAMINER. SUCH AN ACTION SHALL BE CONSIDERED WITHIN THE JURISDICTION OF THE WORKERS`
COMPENSATION FRAUD INSPECTOR GENERAL AND MAY BE REFERRED AS A FRAUDULENT PRACTICE.
It is unlawful for any person who has obtained individually identifiable information from Workers' Compensation Board records to disclose such information to
any person who is not otherwise lawfully entitled to obtain these records. Any person who knowingly and willfully obtains workers' compensation records which
contain individually identifiable information under false pretenses or otherwise violates Workers' Compensation Law Section 110-a shall be guilty of a class A
misdemeanor and shall be subject upon conviction, to a fine of not more than one thousand dollars.
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.
DO NOT SCAN
IME-4 (5-18)
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