Form Mr/ime-1 - Health Provider'S Application For Authorization Under The Workers' Compensation Law

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State of New York
CHECK ONE:
CHECK ONE:
WORKERS' COMPENSATION BOARD
THIS
AGENCY
EMPLOYS
AND
SERVES
q Physician
q Initial Authorization
Medical Director's Office - Riverview Center
PEOPLE
WITH
DISABILITIES
WITHOUT
q Podiatrist
q Reinstatement
150 Broadway - Suite 195
DISCRIMINATION
q Chiropractor
q Change in Rating
Menands, NY 12204
q Psychologist
(Physician only)
1-800-781-2362
HEALTH PROVIDER'S APPLICATION FOR AUTHORIZATION UNDER THE WORKERS' COMPENSATION LAW
IMPORTANT INSTRUCTIONS TO HEALTH PROVIDERS
Complete both sides of this application. Do not fill in shaded area. All entries are to be typewritten or printed clearly. Illegible applications will be returned to the applicant.
Physicians: Submit in duplicate to your County Medical Society. Osteopathic physicians may submit to their County Medical Society or the New York State Osteopathic
Medical Society. A copy of the application (face sheet only) must be filed with the Workers' Compensation Board at the above address at the same time it is submitted to the
Medical Society.
Other Health Providers: Submit to appropriate committee (Podiatry Practice Committee, Psychology Practice Committee, or Chiropractic Practice Committee) at the above
address.
The undersigned hereby makes application to be authorized by the Chair, Workers' Compensation Board for the following: CHECK ALL THAT APPLY
To render appropriate care to persons suffering injury or illness in accordance with the Workers' Compensation Law (WCL), to volunteer firefighters in
accordance with the Volunteer Firefighters' Benefit Law (VFBL) and volunteer ambulance workers in accordance with the Volunteer Ambulance Workers' Benefit
Law (VAWBL), and requests the following rating (physicians only)___________________________________ .
To conduct independent medical examinations (IME's) of persons suffering work-related injury or illness under the WCL, VFBL and VAWBL.
1. Name_________________________________________________________________________ Date of Birth__________________________________
2. Home Address_______________________________________________________________________________________________________________
County___________________________________________________________________ Home Telephone Number____________________________
3. New York State Professional License Number____________________________________ Date License Granted________________________________
4. Office Address(es): List below all of your offices of practice in New York State. Attach an additional sheet of paper if necessary. For each address listed
below, you must have a valid registration certificate from the New York State Education Department. If any of your office addresses are not currently
registered, please call the Division of Professional Licensing Services at (518) 474-3817. Be advised that any address registered with the Education
Department will be given out to claimants.
Principal Office Address_______________________________________________________________________ Office Tel. No.____________________
Street
City
County
Zip Code
Other Office Address__________________________________________________________________________Office Tel. No. ____________________
Street
County
City
Zip Code
5. Major Hospital Affiliations in New York State:
A. Hospital_________________________________________________________________________ Zip Code_________________________________
Clinical Service_______________________________________ Positions Held_________________________Date____________________________
B. Hospital__________________________________________________________________________ Zip Code_________________________________
Clinical Service_______________________________________ Positions Held_________________________Date____________________________
q County Medical Society: County of ____________________________________________
6. Current Professional Society Memberships:
q American Medical Association
q Specialty Societies _________________________________________________________
q Medical Society of the State of New York
q Board Certification, American Board of Medical Specialties
q New York State Osteopathic Medical Society
q Board Certification, American Osteopathic Association
q Board Certification, Other ____________________________________________________
Physicians seeking authorization to conduct Independent Medical Examinations (IME's) must be board certified by a medical or osteopathic specialty board
that is recognized by the Workers' Compensation Board.
7. Graduate of (Professional School) ________________________________________________Degree _____________________ Year _____________
8. Post-graduate study in College or Hospital_______________________________________________________________________________________
9. All psychologists, podiatrists, chiropractors, please attach curriculum vitae including academic training, supervision and experience.
10. Have you completed an authorized or approved residency? q Yes q No
If "yes," attach a copy of the certificate of completion or a letter from a
hospital administrator confirming completion of approved residency.
11. If you have been certified by any specialty board, specify board and date of certification below and attach proof of certification:
a. ___________________________________ Date__________________
b. __________________________________ Date___________________
For Office Use Only - Do Not Fill in Shaded Area
a.
1
3
Rating(s) Given
By:______________
Status
b.
Date of Current Rating
2
4
Med. Reg. Sec.
MR/IME-1 (4-05)
Continued on Reverse

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