Application For Appointment
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1
2Independent Medical Examiner
Application For Appointment
Nebraska Workers’ Compensation Court
402-471-6468 or 800-599-5155
P. O. Box 98908
402-471-2700 (FAX)
Lincoln, NE 68509-8908
Applicant’s Name:
Social Security Number:
Date of Birth:
Address:
City or Town:
State:
Zip Code:
Business Telephone:
EDUCATION AND TRAINING
Dates
Month/Year
Name & Location
From/To
Major
Degree
of Degree
College/University:
Medical School:
Osteopathic School:
Chiropractic School:
Other:
PROFESSION
Specialty:
Subspecialty:
Board certification with:
Board certification with:
Certification expires: _____________
Certification expires: _____________
Have you ever performed an independent medical exam?
Yes
No
If yes, how many years have you been performing IMEs? _____________
What percentage of current practice is IMEs?
List any IME training you have attended:
Please list any experience or education concerning workers’ compensation principles or the Nebraska workers’ compensation system:
Please identify any employer, insurer, attorney, employee group, managed care plan or representatives of any of these to whom you are under contract or who regularly
use your services:
If appointed, what type of cases would you prefer be referred to you?
NWCC Form 62 (03/2009)
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Parent category: Legal