Form Mr/ime-1 - Health Provider'S Application For Authorization Under The Workers' Compensation Law Page 2

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12. Are you employed by any health provider, organization, commercial firm, union or hospital to render care or conduct independent medical examinations?

q Yes q No

If "Yes," explain________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

13. Are you presently, or were you previously, authorized to (a) render care under the Workers' Compensation Law? q Yes q No

If "Yes", give date and

q Yes q No

authorization number:______________________________

(b) conduct independent medical examinations?

If "Yes", give date and

authorization number:_____________________________

14. Have you ever previously applied for authorization to render care or conduct independent medical examinations under the Workers' Compensation Law,

which application was not granted? q Yes q No

15. Was your name ever removed (voluntarily or otherwise) from a list of health providers authorized to render care or conduct independent medical

examinations under the Workers' Compensation Law of any state or under any Federal program? q Yes

q No

If "Yes," give state or program

involved and explain reason for removal:______________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

If your authorization was reinstated, give date of reinstatement ___________________________________________________________________________

16. Have you ever had a professional license suspended or revoked? q Yes

q No

If "Yes," give state or jurisdiction and explain reason:_____________

_______________________________________________________________________________________________________________________________

17. Have you ever had restrictions or limitations placed on a professional license? q Yes

q No

If "Yes," give state or jurisdiction and explain reason:___

________________________________________________________________________________________________________________________________

18. Can you accommodate claimants whose language is other than English? q Yes

q No

If "Yes," please specify: ______________________________

The applicant acknowledges that any authorization granted by the Chair is conditioned upon compliance with the Workers' Compensation Law

and Board Rules, including but not limited to the following:

The applicant shall submit all records and evidence needed for any investigation upon direction by the Chair, Workers' Compensation Board or the local

County Medical Society, or the New York State Osteopathic Medical Society, or the appropriate Practice Committee.

The applicant shall file timely, complete and accurate reports of treatment rendered to claimants, as required by law or regulation or directed by the Chair

or the Board, whenever applicant renders such treatment. Such reports of treatment shall be timely filed as required by the Chair or Board, and shall be

provided upon request to the employer or employer's insurance carrier. The applicant shall transmit copies of medical reports to claimant's licensed

representative or attorney upon receipt of a written request or consent signed by the claimant and accompanied by a notice of retainer, where applicant is

acting as claimant's attending physician or medical consultant.

The applicant shall submit a signed, certified copy of each report of an independent medical examination on the same day and in the same manner to the

Board, the insurance carrier, the claimant's attending physician or other attending practitioner, the claimant's representative and the claimant.

authorized to conduct independent medical examinations, the applicant further agrees to provide such reports and submit to such investigation as may be

required by the Chair.

The applicant shall not undertake or continue the care, or conduct an independent medical examination, of a claimant whose condition requires a

professional service for which he/she is not qualified and authorized by the Chair, Workers' Compensation Board, or which is outside the limits prescribed

by the New York State Education Law for podiatrists, chiropractors, or psychologists, as the case may be. In the event that a case develops a

complication beyond applicant's qualification and authorization, applicant shall promptly refer such case for consultation and/or to the service of a health

provider qualified and authorized to render the needed care or conduct the independent medical examination.

The applicant shall appear before the Board or answer upon request of the Chair, the Board, a Workers' Compensation Law Judge, the appropriate

Practice Committee (if applicable), or any duly authorized officer of the State, any questions in connection with a workers' compensation, volunteer

firefighter or volunteer ambulance worker claim.

The applicant shall refrain from treating subsequently for remuneration, as a private patient, any person seeking medical treatment or submitting to an

independent medical examination in connection with, or as a result of, any injury covered under the Workers' Compensation Law, the Volunteer

Firefighters' Benefit Law, or the Volunteer Ambulance Workers' Benefit Law, if he/she has been removed from the list of health providers authorized to

render such medical care or to conduct such independent medical examination or if the person seeking treatment has been transferred from his/her care

in accordance with the law.

The applicant further shall abide by the provisions of the Workers' Compensation Law and the Rules adopted thereunder.

The undersigned applicant affirms that the foregoing answers are true to the best of his/her knowledge and belief and agrees that if he/she has made any

materially false statement in this application, any authorization granted as a result of this application may be revoked pursuant to the provisions of the Workers'

Compensation Law.

Signature of Applicant___________________________________________________________________ Date__________________________________

APPLICATION RECOMMENDED:

Treatment - Rating Recommended_______________

IME

Physicians only

APPLICATION NOT RECOMMENDED

By: q Medical Society of the County of _______________________________ q New York State Osteopathic Medical Society

q Podiatry Practice Committee

q Chiropractic Practice Committee

q Psychology Practice Committee

Medical Society