Form Ime-5 - Claimant'S Notice Of Independent Medical Examination
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1
2State of New York
WORKERS' COMPENSATION BOARD
CLAIMANT'S NOTICE OF INDEPENDENT MEDICAL EXAMINATION
under Section 137 WCL
WCB CASE NUMBER
CARRIER CASE NUMBER
DATE OF ACCIDENT
DATE OF THIS NOTICE
CLAIMANT'S NAME AND ADDRESS
INSURANCE CARRIER'S NAME AND ADDRESS
DATE OF EXAMINATION
PLACE OF EXAMINATION
THIS EXAMINATION WAS REQUESTED BY
TIME OF EXAMINATION
IF THIS EXAMINATION WAS REQUESTED BY THE CLAIMANT, THE CLAIMANT MAY BE RESPONSIBLE FOR PAYMENT OF THE COST OF THE
EXAMINATION. THE COST OF THIS EXAMINATION WILL BE: (Health provider must indicate exact fee or fee range.)
Exact fee: $________________________________
Fee range: From $____________________ to $____________________
THE INDEPENDENT EXAMINER
INTENDS
DOES NOT INTEND
TO RECORD OR VIDEOTAPE THIS EXAMINATION.
(This notice is invalid if this item is not completed.)
Purpose of Examination/Special Instructions:
You have been scheduled for an independent medical examination in connection with your workers'
compensation claim at the time and place indicated above. YOUR RECEIPT OF BENEFITS COULD
BE DENIED, TERMINATED OR REDUCED AS A RESULT OF A DETERMINATION WHICH MAY
BE BASED ON A MEDICAL EVALUATION MADE AFTER THIS MEDICAL EXAMINATION. You
have the right to videotape or otherwise record the examination. You also have the right to be
accompanied during the exam by an individual or individuals of your choosing. See the reverse of
this form for a complete statement of your rights and obligations under the law with regard to
independent medical examinations.
If for any reason you are unable to appear for this examination, contact ______________________
Name
at __________________________ as soon as possible.
Telephone Number
IME-5 (7-14)
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