Form Lwc-Wc 1015 - Request For Independent Medical Exam
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1Print Form
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RETURN TO:
1
Social Security No
OFFICE OF WORKERS' COMPENSATION, ATTN: Medical Services
2. Date of Injury/Illness
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POST OFFICE BOX 94040
3. Part(s) of Body to be evaluated
BATON ROUGE, LA 70804-9040
4. Date of Birth
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(225) 342-7559
5. OWC Docket Number
TOLL FREE (800) 201-2494
6. OWC District Number
7. Claim # __________________________________
REQUEST FOR INDEPENDENT MEDICAL EXAMINATION
NOTE: THIS REQUEST WILL NOT BE HONORED
UNLESS A DISPUTE HAS ARISEN AS TO
CONDITION OF THE EMPLOYEE AS PER L.R.S. 23:1123.
8.
This form is submitted by:
Employer
Insurer
TPA/Self Insurance Fund
Employee
A.
The choice of the medical practitioner shall be that of the Director of the Office of Workers' Compensation as
per L.R.S. 23:1123.
B.
A cover letter outlining the conflicting medical issue(s) in dispute (reason for request) along with the conflicting medical
reports must be attached to this form.
C.
A list of names, addresses, phone numbers and reports of all physicians/medical providers who have treated or examined the
injured employee for this injury must be included. Indicate who chose each health care provider.
D.
A copy of this request must be signed, dated and mailed to all parties.
EMPLOYEE
EMPLOYEE'S ATTORNEY
9.
Name
10. Name
Street or Box
Street or Box
City
City
State
Zip
State
Zip
Phone (
)
Phone (
)
Fax (
) _________________________________
EMPLOYER
INSURER / ADMINISTRATOR
( circle one )
11. Name
12. Name
Adjuster Name _________________________________
Street or Box
Street or Box
City
City
State
Zip
State
Zip
Phone (
)
Phone (
)
Fax (
) ________________________________
EMPLOYER / INSURER'S ATTORNEY
( circle one )
13. Name ________________________________________
Street or Box __________________________________
City__________________________________________
State
Zip ________
Signature of Applicant
Date
Phone (
)__________________________________
Fax (
) ___________________________________
LWC-WC 1015
REVISED 10/14
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