Free form67-2 - Nebraska

NWCC Form 67-2 (4/08) NOTICE OF AGREEMENT TO USE A NAMED INDEPENDENT MEDICAL EXAMINER

Initiator: 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.
Representing: The parties have agreed to use the physician named below to perform an independent medical examination. Employer/Insurer/Representative Signature Employee/Representative Signature Employee: Name, Social Security #, Address, Telephone, and Attorney's Name (if represented in this case)

Employer: Name, Address, Telephone, and Attorney's Name (if represented in this case)

Insurer:

Name, Address, Telephone, and Attorney's Name (if represented in this case)

Date of Injury:

Description of Injury:

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

Name of Agreed Upon Independent Medical Examiner: ***Signature required if the physician is not on the list of court-appointed independent medical examiners*** I acknowledge that I am not on the list of court-appointed independent medical examiners. However, I agree to perform an independent medical examination for the above employee in accordance with the Nebraska Workers' Compensation Act and the Court's Rules of Procedure (63­65). Physician Signature:
Questions submitted to the independent medical examiner:

Date:

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