Free Alaska Department of Labor and Workforce Development - Workers' Compensation - Alaska

SECOND INDEPENDENT MEDICAL EVALUATION (SIME) FORM
INSTRUCTIONS: (1) Complete all applicable sections of this form ON BOTH SIDES, (2) list the specifics which reflect the SIME dispute in columns four and seven, (3) file this form and one copy of the medical reports reflecting the medical dispute with the appropriate Board office in accordance with 8 AAC 45.072 and (4) file a Request for Conference form. If this form is not signed by all parties, the party preparing this form must serve a copy of this form and the attachments upon all other parties in accordance with 8 AAC 45.060. Employee's Name Employer's Name Date of Injury AWCB Case No

Body Parts in dispute:

Attending Physician(s) Names 1. 2. 3.
2 Phy. No. 3 Report Date 4
Medical Opinion (include report page and item/paragraph #)

Employer Independent Medical Evaluation (EIME) physician(s) Names 1. 2. 3.
5 Phy. No. 6 Report Date 7
Medical Opinion (include report page and item/paragraph #)

1 Dispute(s) / Issue(s)

Causation

Compensability

Treatment (list disputed time periods in Col 4 & 7)

.
Degree of Impairment (state the percent of impairment in Col 4 & 7)

Functional capacity (attach job description)

Medical stability (list disputed time periods in Col 4 & 7)

SIME Form: [Updated for AWCB Bulletin 04-03, December 15, 2004]

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SECOND INDEPENDENT MEDICAL EVALUATION (SIME) FORM (continued)
1 Dispute(s) / Issue(s) 2 Phy. No. 3 Report Date 4
Medical Opinion (include report page and item/paragraph #)

5 Phy. No.

6 Report Date

7
Medical Opinion (include report page and item/paragraph #)

Ability to enter a reemployment plan (attach plan) Non-SIME issue(s) (AS 23.30.110 (g) request) What medical specialty is required for the SIME? Has the employee been seen by any of the following physicians, on the Board's list of examiners, or at the facility where they work? (if yes, check the applicable box) Leonard A. Brant, M.D., F.A.C.S. (urology) Walter Ling M.D. (neurology/psychiatry) William S. Breall, M.D. (cardiology) John J. Lipon, D.O. (orthopedic surgeon) Charles N. Brooks, M.D. (orthopedic surgeon)) Thomas G. Martin, M.D. (toxicology) Paul Brown, M.D. (rheumatology Bruce McCormack, M.D. (neurosurgery) Scott H. Calzaretta, D.C. (chiropractic) John G. McDermott M.D. (orthopedic surgeon) Anthony Buy Corkill, M.C. (neurosurgery) Allene Morris-Scott, M.D. (occupational and environmental medicine) Timothy J. Craven, M.D. (occupational medicine) Neil Pitzer, M.D. (physical medicine and rehabilitation) Don Gregory Davis, D.C. (chiropractic) Paul Puziss, M.D. (orthopedic surgeon) Thomas Dodson, M.D. (forensic psychiatry) Daniel M. Raybin, M.D. (pulmonary) James R. Downey, M.D. (urology) William A. Ross, D.C. (chiropractic) Ronald G. Early, M.D. Ph.D. (psychiatry) Alan C. Roth, M.D. (physical & rehabilitation medicine) Robert F. Foran, M.D. (vascular surgery) Peter F. Roy-Byrne, M.D. (psychiatry) Carol Frey, M.D. (orthopedic, foot/ankle) Jonathan S. Schleimer, M.D. (neurology) Stephen Fuller, M.D. (orthopedic surgeon) Leslie Schofferman, M.D. (pain management) Alan R. Greenwald, M.D. (orthopedic surgeon) Judy Silverman, M.D. (physical medicine/pain management) Thomas H. Gritzka, M.D. (orthopedic surgeon) Morley Slutsky, M.D. (occupational medicine) Kenneth J. Hammerman, M.D. (gastroenterology internal medicine) Douglas G. Smith, M.D. (orthopedic surgeon) Dana Headapohl, M.D. (occupational medicine) Samuel M. Sobol, M.D. F.A.C.C. F.A.C.P. (cardiology, cardiovascular disease, internal medicine) Richard Hogson, M.D. (otolaryngology) Paul L. Steer, M.D. F.A.C.P. (internal medicine & infectious diseases) Edward Holmes M.D. (occupational medicine) Kenneth Swayman, D.P.M. (podiatry medicine and surgery) Craig B Johnson, D.C. (chiropractic) Ronald N. Turco, M.D. (psychiatry) James C. Klein, M.D., D.D.S. (otolaryngology/ oral and maxillofacial surgery) Christopher S. Wilson, M.D. (hand and upper extremity surgery) Sanford A. Lazar, M.D. (orthopedic surgeon) Leon Zeitzer, M.D. (otolaryngology) Larry A. Levine, M.D. (physical medicine and rehabilitation)
Employee Employer (each party must check applicable boxes. If the parties agree on any statement below, it constitutes a stipulation under 8 AAC 45.050). - Based upon the above information, an SIME dispute exists under AS 23.30.095(k) - The right to have the board determine the need for an SIME is waived. A workers' compensation officer or the board designee may decide whether or not to order an SIME. - Non-SIME issues, noted above, should be submitted to the board's examiner under AS 23.30.110(g). The right to have the board require an examination is waived. A workers' compensation officer or the board's designee may decide whether or not to order an examination, in conjunction with an SIME, under AS. 23.30.110(g). The employer will pay for the cost of this examination. An examination by the board's examiner is considered to be an SIME. No subsequent SIME will be ordered on the non-SIME issues noted above. - This form amends the issues in an active application or petition previously filed by a party. The requirement to serve and file an answer to the application or petition as amended by this SIME form, is waived. IF THERE IS NO ACTIVE APPLICATION OR PETITION IN THIS CASE, THE PARTY PREPARING THIS FORM MUST ATTACH AN APPLICATION OR PETITION TO COMMENCE PROCEEDINGS Signature(s) ___________________________ Employee or representative _________________________ Date _______________________________________ Employer, Insurer or representative ___________________ Date _

SIME Form: [Updated for AWCB Bulletin 04-03, December 15, 2004]

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