Free REQUEST FOR APPOINTMENT OF IME, VRE MCM_FINAL.pub - Oklahoma

REQUEST FOR APPOINTMENT OF INDEPENDENT MEDICAL EXAMINER, REHABILITATION EVALUATOR, OR MEDICAL CASE MANAGER
COURT FILE NO. Full Name of Claimant (Injured Employee) Claimant's Mailing Address City Claimant's Date of Birth Name of Treating Physician Treating Physician Mailing Address City State Zip Code State Zip Code Claimant's Telephone Number ( ) Claimant's Social Security No. THIS SPACE FOR COURT USE ONLY: Revised 6/13/06 IME Physician or Rehabilitation Evaluator or Medical Case Manager BODY PARTS Name of Respondent (Employer) Name of Insurer Date of Injury

IME Requested By: IME Physician Selected By:

Claimant Parties

Respondent Court

Issues: 1.____ IS THE TREATING PHYSICIAN'S OPINION/REPORT, DATED ____________(insert date), SUPPORTED BY OBJECTIVE MEDICAL EVIDENCE? IF NOT, SUBMIT A VERIFIED OR DECLARED WRITTEN NARRATIVE REPORT TO THE COURT AND THE PARTIES ADDRESSING ONLY THE FOLLOWING ISSUE(S) [specify issue(s)]: a.___ b.___ c.___ d.___ e.___ f.___ g.___ h.___ i.___ j.___ k.___ l.___ Is the claimant currently temporarily totally disabled? Was claimant temporarily totally disabled from _______ to _______? Is claimant in need of additional treatment? Treatment is not authorized. Does claimant need pain management? Diagnostic testing that is reasonable and necessary to respond to the issues specified in this order is authorized. Physician is requested to make specific recommendations regarding treatment, including any necessary maintenance care. If treatment is not needed, or if claimant has reached maximum medical improvement, physician is requested to rate nature and extent of permanent partial impairment, if any. Physician is requested to address causation. Physician is requested to address the issue of apportionment, if applicable. Physician to address whether the claimant has suffered a change of condition for the worse. Physician to address whether the claimant is permanently and totally disabled. Physician to address whether vocational rehabilitation is indicated (i.e. whether as a result of the injury the claimant is unable to perform the same occupational duties the claimant was performing before the injury).

2.____ PER 85 O.S., SECTION 17(D)(10), IS THE CLAIMANT IN NEED OF FURTHER MEDICAL TREATMENT? PHYSICIAN IS REQUESTED TO MAKE SPECIFIC RECOMMENDATIONS REGARDING TREATMENT. TREATMENT IS NOT AUTHORIZED. 3.____ PHYSICIAN IS TO REVIEW THE MEDICAL RECORDS OF THE EMPLOYEE, EXAMINE THE EMPLOYEE, OR BOTH, AS NECESSARY TO RENDER AN OPINION PER 85 O.S., SECTION 201.1 ON WHETHER OR NOT PRIOR AUTHORIZATION SHOULD BE GRANTED FOR TREATMENT OUTSIDE TREATMENT GUIDELINES ADOPTED AS PROVIDED IN TITLE 85 OF THE OKLAHOMA STATUTES. 4.____ Medical examination of the claimant by the independent medical examiner is authorized by agreement of the parties. 5.____ Counselor is to perform rehabilitation evaluation, including recommendation for vocational retraining plans, if appropriate. 6.____ Counselor is to determine transferable skills. 7.____ Counselor is to provide job placement assistance. Special Instructions:

Claimant's Attorney, if represented

OBA#

Judge

Respondent's Attorney

OBA#

Date