Free form62_20090331.pmd - Nebraska

Independent Medical Examiner

Application For Appointment
Nebraska Workers' Compensation Court State Capitol Building P. O. Box 98908 Lincoln, NE 68509-8908
Applicant's Name:

402-471-6468 or 800-599-5155 402-471-2700 (FAX) http://www.wcc.ne.gov/
Social Security Number: Date of Birth:

Address:

City or Town:

State:

Zip Code:

Business Telephone:

EDUCATION AND TRAINING
Name & Location College/University: Medical School: Osteopathic School: Chiropractic School: Other: Dates From/To Major Degree Month/Year of Degree

PROFESSION
Specialty: Subspecialty:

Board certification with:

Board certification with:

Certification expires: _____________ Have you ever performed an independent medical exam? What percentage of current practice is IMEs? List any IME training you have attended: Yes No

Certification expires: _____________ If yes, how many years have you been performing IMEs? _____________

Please list any experience or education concerning workers' compensation principles or the Nebraska workers' compensation system:

Please identify any employer, insurer, attorney, employee group, managed care plan or representatives of any of these to whom you are under contract or who regularly use your services:

If appointed, what type of cases would you prefer be referred to you?

NWCC Form 62 (03/2009)

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Independent Medical Examiner -- Application For Appointment
Nebraska State License # Are you currently licensed in any other state? Yes No Tax I.D. # If yes, please list state and license #: Drug Enforcement Agency #

List any other registrations, certifications or licenses you possess:

Have you ever been subject to disciplinary action?

Yes

No

If yes, please explain:

Have you ever voluntarily surrendered your license?

Yes

No

If yes, please explain:

PRACTICE HISTORY
Present practice name and location: Name: Address: List other site addresses if applicable: Prior practice name(s) and location(s): 1. Name: Address: City, State & Postal Code: 2. Name: Address: City, State & Postal Code: 3. Name: Address: City, State & Postal Code: Telephone: From: __________ To: __________ Telephone: From: __________ To: __________ Telephone: From: __________ To: __________ Type of Practice: From: __________

I request appointment to the list of independent medical examiners maintained by the Nebraska Workers' Compensation Court. I will provide independent, impartial and objective medical findings in all cases that come before me. I will decline a request to serve as an independent medical examiner only for good cause shown. If I determine an examination is necessary, I will contact the employee within 10 business days after receipt of records from all parties to schedule an appointment. I will submit a written report within 10 business days following receipt of all necessary records and information, the completion of an examination, or the completion of any required tests, whichever is applicable. I will accept the fees established pursuant to Rule 65 as payment in full for services rendered as an independent medical examiner. I will submit to a review pursuant to Rule 62, E. I have read and understand Rule 62 though Rule 66 of the Nebraska Workers' Compensation Court, which describe the independent medical examiner system. I agree to comply with all of the provisions of these rules. I hereby attest that the information contained in this application is correct to the best of my knowledge and belief. I understand that false or misleading information may result in the rejection of my application or in my removal from the list if I am appointed.

SIGNATURE NWCC Form 62 (03/2009)

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