Free form63-1 - Nebraska

NWCC Form 63-1 (Rev. 4/08)

REQUEST FOR INDEPENDENT MEDICAL EXAMINER
Requester Name, Address, and Telephone:

Nebraska Workers' Compensation Court State Capitol Building P.O. Box 98908 Lincoln, NE 68509-8908

800-599-5155 402-471-6468

Attach a separate sheet of paper to add additional information.
Employee Name, Social Security #, Address, and Telephone: Representing:

Employer Name, Address, and Telephone: Date of Injury: Description of Injury:

Identify All Attorneys Currently Representing Any Party by Name, Address, Telephone, and Client Name: Insurer Name, Address, and Telephone:

Name, Address, and Specialty of all physicians who have treated or examined the employee for this injury:

Define the disputed medical issues which require the opinion of an Independent Medical Examiner.

List the specific questions related to the disputed medical issues that you wish to be submitted to the examiner.

Preferred specialty, if any, of independent medical examiner. The court is not bound by such preference.

Submit with certificate of service as proof that all other parties have been served a copy of the request.