Information & Instructions About Your IME

Please correct the errors described below.

I understand that I am here for an independent medical examination (IME), which means the doctors(s) performing the evaluation is neither treating me nor an employee of whomever requested the IME (insurance company, third party administrator, attorney, governmental agency, employer, or physician). I understand the purpose of the independent medical examination is to provide a thorough, objective evaluation of the specific condition(s) related to my injury or illness which is in question, as well as prior subsequent conditions that might affect it, and to answer whatever questions the requesting party has. This sheet outlines the process, my rights, and my responsibilities.

This IME is not a comprehensive medical examination. I understand it will not provide advice or treatment to me or substitute for evaluation or treatment by my regular treating doctor. I understand a patient/physician relationship is not established between the evaluating physician and me. Accordingly, there is no patient/physician privilege associated with this evaluation. Usually a written report will be prepared summarizing today's evaluation and sent to the requesting party.

If I would like a copy of the report, I will contact them.

I understand that generally the evaluation will begin with the doctor obtaining a history of how my problem began and what evaluation or treatment has been rendered since. Utilizing information I provide verbally and on the history forms, as well as that contained within whatever records may be available for review. The doctor well then ask about my current symptoms and record a relatively brief past medical and other information such as my work status, etc. All information which I provide may be included in the report.

After the interview, a physical examination of the relevant body part(s) will be conducted. I understand that I need not perform any maneuver I feel might cause injury or a worsening of my symptoms, and will immediately inform the examiner if anything he is doing is causing excessive discomfort so it can be stopped right away. Some pain, stiffness, or other symptoms are produced in most physical examinations of this sort. For instance, when touching a tender spot or checking how far a stiff joint can move, and such findings are helpful in understanding the condition. The IME, however, is not intended to cause injury or excessive pain. I understand that in order to avoid that I must fulfill my responsibility to inform the doctor(s) if there is something I can't do, a certain test is causing too much discomfort, etc.

I also understand that I will be permitted to have a family member or friend, who is not a licensed clinical practitioner, present during the physical examination . It may be necessary to obtain additional x-rays or other diagnostic tests in order to answer certain question. These may be performed here or at another facility.

I have read and understand the aforementioned information and instructions . I authorize this physician or any co-examiner to obtain any information that may be of relevance to the condition(s) in question, and to release that information and the results of the IME (verbally or in writing) to any entity who has requested the IME.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Independent Medical Evaluation Questionnaire

We will be seeing you soon for your independent medical evaluation. We pledge that we will be both thorough and impartial. During this visit no treating physician/patient relationship will be established. The purpose of this visit is to answer specific questions concerning your case and to prepare a report. The information that you share with us will be included in the report. If anyone else needs a copy of this report, it is required that they obtain it directly from the organization requesting this evaluation.

During the visit we will review your history, medical records, and any available studies. We will also perform a physical examination. If you have any difficulties whatsoever during the assessment you should let us know immediately. To adequately understand your case, we need to carefully review your history. Please complete this questionnaire and bring it with you to the examination. We will review all of this information at the time of your visit. We look forward to seeing you.

*If you are not having difficulty with pain, proceed to question 18

17. On a scale from 0 (no pain) to 10 (excruciating pain):

*If your injury is not work-related, please proceed to question 28.

Yes but I quit

I understand that I am being seen for an independent medical evaluation and no treating physician/patient relationship is established. I understand that the information I discuss will be included in a report that is prepared for the requesting client. I consent to this report being sent to this client and to participating in the assessment. I agree to advise the physician immediately if I experience any difficulties during the examination

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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