Free Employee Waiver of Examination by Personal Physician - SF 53913 - Indiana

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EMPLOYEE WAIVER OF EXAMINATION BY PERSONAL PHYSICIAN
State Form 53913 (4-09)

INDIANA WORKER'S COMPENSATION BOARD 402 West Washington Street, Room W196 Indianapolis, IN 46204

INSTRUCTIONS: Please have claimant complete this form. Submit together with Agreement to Compensation (Form 1043).

I have read the report of Dr. 20 the

, dated the

day of ________________,

, and understand that this medical opinion states that I have a __________% permanent partial impairment of as a result of injuries sustained in the above mentioned accident.

I,

, understand that, pursuant to the Workers Compensation Act of

Indiana, I have the right to have an examination by a qualified physician of my choice, at my own expense, for the purpose of determining what degree of permanent partial impairment, if any, I may have as a result of injuries suffered on the day of , 20 , while in the employ of .

I understand that any impairment rating obtained from such an examination is not binding upon the employer or insurance carrier, although it may be taken into consideration.

I do not wish to have an examination by a physician of my own choice and I hereby accept and agree with the opinion of Dr. concerning the extent of my permanent injuries as described in

the attached report. I understand that this waives only my right to an examination by a physician of my own choosing regarding this particular settlement.

Signed and dated this

day of

, 20

.

X Signature of Employee