Form Ldol-Wc 1015 - Request For Independent Medical Examination

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RETURN TO:
1
Social Security No
OFFICE OF WORKERS' COMPENSATION
2. Date of Injury/Illness
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POST OFFICE BOX 94040
3. Part(s) of Body Injured
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
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.
7.
This form is submitted by:
__
Employee
__
Employer
__
Insurer
__
TPA/Self Insurance Fund
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 mailed to all parties.
EMPLOYEE
EMPLOYEE'S ATTORNEY
8.
Name
9. Name
Street or Box
Street or Box
City
City
State
Zip
State
Zip
Phone (
)
Phone (
)
EMPLOYER
INSURER / ADMINISTRATOR
( circle one )
10. Name
11. Name
Street or Box
Street or Box
City
City
State
Zip
State
Zip
Phone (
)
Phone (
)
EMPLOYER / INSURER'S ATTORNEY
( circle one )
12. Name
Street or Box
City
State
Zip
Signature of Applicant
Date
Phone (
)
LDOL-WC 1015
REVISED 1/98

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