Form F245-383-000 "Independent Medical Examination Fax Cover Sheet" - Washington

What Is Form F245-383-000?

This is a legal form that was released by the Washington State Department of Labor and Industries - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2008;
  • The latest edition provided by the Washington State Department of Labor and Industries;
  • 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 F245-383-000 by clicking the link below or browse more documents and templates provided by the Washington State Department of Labor and Industries.

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Download Form F245-383-000 "Independent Medical Examination Fax Cover Sheet" - Washington

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INDEPENDENT MEDICAL EXAMINATION
FAX COVER SHEET
_________________
_________
Worker name
Claim
_________
Claim
_________
Claim
Exam Report
Addendum to exam dated _____________
Job Analyses / Physical Capacities Information attached
____________________________________________________
IME FIRM
____________________________________________________
IME EXAMINER
_____________________________________________________
CONTACT NAME
_____________________________________________________
CONTACT PHONE NUMBER / EXTENSION
_____________________________________________________
CONTACT FAX NUMBER
RESET
INDEX TO: IME
F245-383-000 IME fax cover sheet 12-2008
INDEPENDENT MEDICAL EXAMINATION
FAX COVER SHEET
_________________
_________
Worker name
Claim
_________
Claim
_________
Claim
Exam Report
Addendum to exam dated _____________
Job Analyses / Physical Capacities Information attached
____________________________________________________
IME FIRM
____________________________________________________
IME EXAMINER
_____________________________________________________
CONTACT NAME
_____________________________________________________
CONTACT PHONE NUMBER / EXTENSION
_____________________________________________________
CONTACT FAX NUMBER
RESET
INDEX TO: IME
F245-383-000 IME fax cover sheet 12-2008