Free Your Independent Medical Exam - Washington

Your Independent Medical Exam
Answers to some of the most commonly asked questions about independent medical exams (IMEs).
Why has a medical exam been scheduled for me?
A medical exam has been scheduled for you to ensure that you receive appropriate care for your workplace injury or occupational disease. Medical exams are required for any of the following reasons:
n n n n n

Who will do the exam?

A doctor will examine you. In some cases, several doctors may conduct the exam or a series of exams.

Your doctor, employer or claim manager asked for an evaluation of your condition. We need to evaluate the extent of your impairment. There is a question about the type or duration of treatment you need. You asked to have your claim closed, reopened or allowed. You appealed our decision regarding your claim or are asking us to reconsider.

May I bring a friend or relative to the exam?

Yes, but he or she cannot be paid or have expenses reimbursed. If you are scheduled for a psychiatric exam, your companion will not be allowed in the examination room. You should not bring minor children to an IME exam.

What if I am asked to bring x-rays, MRIs or CT scans to the exam?

How will I be notified about the medical exam?

If you need help obtaining the x-rays, MRIs or CT scans, contact your doctor's office.

At least 14 days before the scheduled exam, the Department of Labor & Industries (L&I) will send you a letter stating where and when it will take place. It is your responsibility to keep your appointment.

What will happen at the exam?

What if my exam needs to be rescheduled?

If you have good reason for rescheduling your exam and you give L&I enough notice, your claim will not be affected. To reschedule, you must call the number listed on your letter or the IME scheduling unit, 1-800-468-7870 at least five working days before the exam

Usually, the examining doctor will check only the conditions that apply to your claim, ask you about your medical history, and review medical information in your claim file. He or she may suggest treatment for your personal doctor to try, but he or she will not be treating you. Your examination may be brief. You should not expect a complete physical exam. However, in some cases a full exam, lab tests and x-rays may be needed. This will be the examining doctor's decision.

Will I have to pay for the exam?

L&I will pay any costs for the examination if you appear and cooperate. If you fail to attend the exam without good cause, your time-loss benefits may be reduced by the amount of the examination charge. You also might jeopardize other benefits.

What if I have to miss work?

If you have to take more than 30 minutes off work (without pay) to attend your independent medical examination set up by the department, you may be compensated for the actual hours missed. You will be reimbursed for time lost from work based on your hourly wage at the time of the examination. Please see the attached form, IME Travel & Wage Reimbursement Request.

Please fill out the form carefully. If you submit incomplete or incorrect information, we may have to return the form to you to correct. Send your completed form and receipts to: Department of Labor & Industries PO Box 44267 Olympia, WA 98504-4267

Form Instructions

Who will pay my travel expenses?

In most cases, L&I will reimburse travel expenses. When necessary, meals, hotel expenses, taxi fare, parking costs, and ferry and bridge tolls will be paid at the current department rate. Please obtain receipts for these expenses. If you travel to your examination by airplane, bus or train, contact the IME scheduling unit, 1-800-468-7870. L&I will make necessary arrangements for your travel.

Here's how to get more help
If you have questions about your scheduled exam, please contact the Department of Labor & Industries' IME scheduling unit at 1-800-468-7870. If you wish to send us comments about your exam experience, you may call the IME Comment Line at 1-888-784-8059. If you have other questions about your claim, please call our Office of Information and Assistance at 1-800-547-8367.

What if I have a physical or mental disability that limits how I can travel to a medical exam?

Contact the IME scheduling unit at 1-800-468-7870 so arrangements can be made to assist you in traveling to the exam. The disability does not need to be related to your claim.

How do I get paid for lost wages and travel expenses?

You must complete the attached reimbursement request form and submit it, along with your receipts, within one year of the exam. You must sign the form. (See Form Instructions.)

8 On the Web: Visit the L&I Web site at: www.Lni.wa.gov

Other formats for persons with disabilities are available on request. Call 1-800-547-8367. TDD users, call 360-902-5797. L&I is an equal opportunity employer. PUBLICATION F245-224-000 [03-2008] (Also printed in Spanish. Request Publication F245-224-999)

NO STAPLES IN BAR CODE AREA

INDEPENDENT MEDICAL EXAM (IME) TRAVEL & WAGE REIMBURSEMENT REQUEST
Send to: Dept. of Labor and Industries PO Box 44267 Olympia WA 98504-4267

DO NOT WRITE IN SPACE

Claim No.

Injured Worker Information
Worker's name
(Last, First, Middle Initial)

Date of injury Apt # State ZIP Social Security No. (for ID only) Worker's Phone Number

Worker's home address (not PO Box) City

(

)

Travel Information
Read the instructions on the back of this form before you complete this section.
A
Date of Each Trip (mm-dd-yyyy)

B Travel
Code (one per line)

C

From: (City)

D

To: (City, Person Seen)

E

No. Of Miles (Round Trip)

F

Cost For Food, Lodging, Fares, Parking, Wages (one per line)

$ $ $ $ $ $ $ $ $

Reimbursing Wages:
If you took more than 30 minutes of time off work without pay to attend your Independent Medical Exam (IME), we will reimburse you for the time you missed. You will be reimbursed the hourly wage you were making at the time of the IME. Please list total time and wages here: Time missed from work to attend the IME: ___________Hrs ___________ Min.
Employer's name

Hourly wage at the time of the IME: $ ______________
Employer's phone number

Address

City

State

ZIP + 4

Worker's Signature

(forms not signed will be returned)

These expenses are related to my workers' compensation claim and I have not been reimbursed for them. I understand it is a crime to submit information I know is false. I have read and understand the instructions on the back of this form.
Date

Worker's signature

F245-224-000 ime travel and wage reimbursement request 03-2008

Read the instructions carefully before you complete this form! We can only reimburse you if your form is complete, correct and signed.
1. Use this form for IME travel only If you traveled for any other reason, please call the Provider Hotline at 1-800-848-0811 for the correct reimbursement form F245-145-000. 2. Send your form soon We can only reimburse you if we receive your completed form within 1 year from the date of your exam. 3. Fill out each column correctly Column A: Write the date you traveled (only one date per line). Column B: From below, fiind the code that describes your travel expense (only one code per line). For example, if you traveled in a private vehicle to your IME, write in 0412A. Travel Codes for Independent Medical Exams (IME) 0411A 0412A 0402A 0403A 0405A 0406A 0407A 0408A 0409A 0414A Total time you lost from work (hours x wage) for attending a department or self-insured exam Private vehicle mileage to travel to a department or self-insured exam Parking (receipt required for $10 and over) Bridge and ferry tolls (receipt required) Commercial transportation (receipt required) Lodging (receipt required) Breakfast (receipt required) Lunch (receipt required) Dinner (receipt required Taxi (receipt required)

Column C: Write the city you were traveling from. Column D: Write the city you traveled to for your medical exam and the name of the doctor(s). Column E: If you are requesting mileage, write the total number of miles you traveled round trip. You will be paid at the corrent mileage rate, according to the shortest direct route from your home. Column F: Did you have expenses for food, lodging, fares, parking or wages? If so, fill out Columns A and B and write the dollar amount of each expense in Column F (only one cost per line). You must attach all receipts. Send in photocopies of your receipts and keep your originals. All receipts must be itemized and legible. Credit card statements are not acceptable. Example:
A. Date (Each Trip) B Travel Code (one per line) C From: (City) D. To: (City, Person Seen) E No. of Miles (Round Trip) F Cost for Food, Lodging, Fares, Parking, Wages (one per line)

1.

9/25/02

0412a

Olympia

Seattle Dr. Smith

60

2. 3.

9/25/02 9/25/02

0411a 0402a

(Mileage cost will be calculated for you at the current department rate). $ 50.00 $ 3.00

4. Mail this form to:

Dept of Labor and Industries PO Box 44267 Olympia WA 98504-4267

F245-224-000 ime travel and wage reimbursement request 03-2008