LAC 40:I.6727. Request for Independent Medical Examination; Form LW-WC-1015

RETURN VIA MAIL ONLY TO: 1. Social Security No. - - _____ OFFICE OF WORKERS' COMPENSATION 2. Date of Injury/Illness - - _ ATTN: MEDICAL SERVICES 3. Part(s) of Body Injured_____________________________ POST OFFICE BOX 94040 __________________________________________________ BATON ROUGE, LA 70804-9040 4. Date of Birth - - _____ PHONE: (225) 342-2030 5. No 1008/suit is pending  (check if applicable) TOLL FREE (800) 201-2494 6. OWCA Docket Number _____________________________ 7. OWCA District Number_____________________________ 8. Claim Number:_____________________________________ REQUEST FOR La. R.S. 23:1123 INDEPENDENT MEDICAL EXAMINATION Issues in Dispute (check all that apply):  Employee’s condition  Employee’s capacity to work The Assistant Secretary of the Office of Workers’ Compensation shall choose the medical practitioner to conduct the IME per La. R. S. 23:1123. B. All requests to the OWCA for an IME shall include the following: A cover letter explaining the conflicting medical issue(s) in dispute (reason for request) along with the conflicting medical reports must be attached to this form. The reports that document the dispute shall be most current. A list of names, addresses, and phone numbers of all physicians/medical providers who have treated or examined the injured employee for this injury. For each physician/medical provider listed, please state which party chose the provider. C. The submitting party shall mail a copy of this request and all included documents to all parties and their attorneys on the same day. D. The Assistant Secretary will not appoint an IME unless there is a dispute as to the employee’s condition or capacity to work pursuant to La. R.S. 23:1123. E. Upon notice that your request for an IME is granted, you shall forward medical documents from all parties’ medical providers (including but not limited to applicable reports, notes, test results, FCEs, X-rays, MRIs, and CT scans) to the IME physician’s office with a copy of the OWCA IME Agreement and the OWCA letter to the doctor. Do not attach a private cover letter. You shall forward a statement to all parties and their attorneys identifying any films provided to the IME by provider name, type, and date of service in addition to identical copies of all documents, excluding films, you sent to the IME physician’s office. F. You shall not communicate verbally or in writing with the IME prior to the IME rendering the IME report unless otherwise directed by Medical Services for limited processing issues. G. The type of indemnity benefit, if any, an employee may be entitled to is a legal determination outside of the scope of the IME. EMPLOYEE EMPLOYEE'S ATTORNEY 9. Name 10. Name Street or Box Street or Box City City State Zip State Zip Phone ( ) Phone ( ) Fax ( )___________________________________ Bar Roll # ___________________________________ Email: _______________________________________ EMPLOYER  INSURER or  THIRD PARTY ADMINISTRATOR (check one) 11. Name 12. Name Street or Box Adjuster’s Name ______________________________ City Street or Box State Zip City Phone ( ) State Zip Fax ( )_________________________________ Phone ( ) Fax ( )____________________________________ Email: _______________________________________ ATTORNEY FOR  EMPLOYER  INSURER (check all that apply) 13. Name Street or Box City State Zip Phone ( ) Fax ( )_________________________________ Bar Roll #: _________________________________ Email: ___________________________________ __________________________________________________ _____________ Signature of Applicant Date _________________________________________________ Name of Applicant LW-WC-1015 Rev. 11/25