Cc-Form-M - Request For Appointment Of Independent Medical Examiner, Rehabilitation Evaluator, Or Medical Case Manager
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1WORKERS’ COMPENSATION COMMISSION
CC-FORM-M
REQUEST FOR APPOINTMENT OF INDEPENDENT MEDICAL EXAMINER,
REHABILITATION EVALUATOR, OR MEDICAL CASE MANAGER
COMMISSION FILE NO.
Claimant’s Social Security No. (LAST 4
THIS SPACE FOR COMMISSION USE ONLY:
Revised 12 - 18 - 14
DIGITS ONLY)
XXX-XX-___________________
NAME OF:
IME Physician
Rehabilitation Evaluator
Medical Case Manager
Full Name of Claimant (Injured Employee)
Claimant’s Mailing Address
BODY PARTS
City
State
Zip Code
Name of Respondent (Employer)
Claimant’s Date of Birth
Claimant’s Telephone Number
(
)
Name of Insurer
IME Requested By:
Claimant
Respondent
Commission
Mutual Agreement
Date of Injury
Issues:
IME Physician Selected By:
Parties
Commission
1.____ Is the claimant currently temporarily totally disabled?
2.____Was claimant temporarily totally disabled from ____________________ to ___________________?
3.____Is claimant in need of additional medical treatment? Treatment is not authorized.
4.____Physician is requested to make specific recommendations regarding treatment.
5.____Does claimant need pain management?
6.____Does claimant need continuing medical maintenance?
7.____In relation to an objection to termination of temporary total disability, is the claimant in need of further medical
treatment? Physician is to make specific recommendations regarding the reasonableness and necessity of further
medical treatment. Treatment is not authorized unless agreed upon by the parties.
8.____Is the surgery that is recommended by the treating physician reasonable and necessary?
9.____Is the claimant’s medical treatment recommended care under the Work Loss Data Institute’s Official Disability
Guidelines (ODG) or the Physician Advisory Committee Guidelines (PACG)?
10.____If treatment is not needed, or if claimant has reached maximum medical improvement, physician is to rate the nature
and extent of permanent partial disability, if any.
11.____Physician is requested to determine causation of claimant’s complaints. If determined to be work-related, then:
(identify issues) ________________________________________________________________________________.
12.____Physician is requested to address the issue of apportionment, if applicable.
13.____Physician to determine if the claimant has suffered a change of condition for the worse.
14.____Physician to determine if the claimant is permanently and totally disabled.
15.____Physician is directed to review a videotape which shall be provided by the respondent. The cost of the physician’s
review shall be borne by the respondent in accordance with Commission Rule 810:15-9-5. After reviewing, the
physician shall address: (identify issues)
16.____Physician to determine if the claimant is permanently and totally disabled as a result of the combination of injuries.
17.____Physician to address if vocational rehabilitation is indicated (i.e. whether as a result of the injury the claimant is unable
to perform the same occupational duties the claimant was performing before the injury).
18.____Counselor is to perform rehabilitation evaluation, including recommendation for vocational retraining plans, if
appropriate.
19.____Counselor is to determine transferable skills.
20.____Counselor is to provide job placement assistance.
Authorizations:
1. _____Diagnostic testing that is reasonable and necessary to respond to the issues specified in this order is authorized.
2. _____Other:
Special Instructions:
Claimant/Claimant Attorney, if represented
OBA#
Administrative Law Judge
Opposing Party/Counsel
OBA#
Date
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