Order Appointing Independent Medical Examiner Template
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1STATE OF OKLAHOMA WORKERS’ COMPENSATION COURT OF EXISTING CLAIMS
ORDER APPOINTING INDEPENDENT MEDICAL EXAMINER
DOCTOR_______________________________BODY PART(S)____________________________________________________
(Physician and Body Part(s) to be seen must be on the IME list)
In re Claim of:
THIS SPACE FOR COURT USE
Claimant Name (Injured Employee)
Claimant’s Date of Birth
Claimant’s Social Security Number (LAST 4 DIGITS ONLY)
Claimant’s Phone Number
Employer Name (Respondent)
FILE NO.
Employer’s Insurance Carrier
Date of Injury
IME Requested By: Q Claimant Q Respondent Q Agreement
IME Selected By: Q Parties Q Court
Q
Court’s own motion
Revised 12/10/14
RESPONDENT
THE
SHALL PROVIDE THE DESIGNATED PHYSICIAN WITH A FILE-STAMPED COPY OF THIS
ORDER AND SCHEDULE AN APPOINTMENT WITHIN 7 DAYS OF ORDER RECEIPT AND NOTIFY THE CLAIMANT
(Original Order to Order Department - Certified Copies Mailed to Parties)
ISSUES:
1. ____ Is 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 to make specific recommendations regarding treatment.
5. ____ Does claimant need pain management?
6. ____ Physician is to render an opinion regarding the nature and extent, if any, of continuing medical maintenance.
7. ____ Physician is to render an opinion regarding the reasonableness and necessity of surgery recommended by the
treating physician.
8. ____ Physician is to render an opinion whether or not medical treatment provided according to either the work
loss data institute's Official Disability Guidelines (ODG) or the Oklahoma Treatment Guidelines (OTG), as
applicable, is in the best interests of the employee.
9. ___
Diagnostic testing that is reasonable and necessary to respond to the issues specified in this order is
authorized.
10. ___ If treatment is not needed or if claimant has reached maximum medical improvement, physician is requested
to rate nature and extent of permanent partial impairment, if any.
11. ___ Physician is to render an opinion regarding causation of claimant's complaints.
12. ___ Physician is to address the issue of apportionment, if applicable.
13. ___ Physician is to render an opinion whether claimant has suffered a change of condition for the worse.
14. ___ Physician is to render an opinion whether claimant is permanently and totally disabled.
15. ___ Physician is directed to review a videotape which shall be provided by the respondent.
16. ___ Physician is to render an opinion whether claimant is permanently and totally disabled as the result of the
combination of injuries.
17. ___ Physician to address if vocational rehabilitation is indicated.
18. ___
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
BY ORDER OF __________________________________________
COURT OF EXISTING CLAIMS JUDGE
Print Claimant/Counsel
Print Employer-Respondent//Counsel
Phone Number
Fax Number
Phone Number
Fax Number
Address (Number and Street)
Address (Number and Street)
City
State
Zip
City
State
Zip
Adjuster Name/Phone Number
WORKERS’ COMPENSATION COURT OF EXISTING CLAIMS • 1915 NORTH STILES STE 127 • OKLAHOMA CITY, OKLAHOMA 73105-4918
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