Healthcare Adult IME Form

Healthcare Adult IME Form

Patient Information

Date of Birth:    Gender (check one): Male   Female   Other

Insurance Information

Referral and Exam Request

Claim/Reference Number:    Date of Injury/Incident:

Orthopedic   Neurological   Psychiatric/Psychological   Other

Medical History and Current Status

Authorization to Release Medical Records for IME

I hereby authorize any physician, health care provider, hospital, clinic, medical office, pharmacy, insurer or other entity that has provided medical services to me to release and disclose my medical records, including but not limited to clinic notes, operative reports, imaging studies, laboratory reports, pharmacy records, and billing information, to the independent medical examiner(s) and the requesting entity for the purpose of the Independent Medical Examination (IME). This authorization includes disclosure of records related to mental health and substance use disorder treatment if such records are relevant to the IME.

I understand that the records disclosed pursuant to this authorization may be used in connection with medical evaluation, opinion, and reports prepared for use in claims, litigation, insurance determinations, or other administrative proceedings. I understand that the information disclosed pursuant to this authorization may include information protected by state or federal privacy laws.

Medical history and clinic notes   Imaging (x-ray, MRI, CT)   Laboratory reports   Pharmacy/Prescription records   Billing records

This authorization will expire on: . I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.

IME Consent and Acknowledgment

I consent to undergo an independent medical examination which may include history, physical examination, functional testing, mental status examination, photographic documentation, review of medical records, and diagnostic testing as deemed necessary by the examiner. I understand the IME is an independent evaluation requested by the requesting entity and does not create a treating physician-patient relationship with the examiner.

I understand the examiner will prepare a written report summarizing findings and opinions that may be provided to the requesting entity and other parties involved in my claim or legal matter. I understand that I may be billed separately for the IME in accordance with the requesting entity's arrangements.

By signing this form I agree to cooperate with the IME process. I acknowledge that failure to appear for a scheduled IME without prior notice may result in adverse administrative or claim-related consequences.

I acknowledge that I have read and understand the IME purpose and this authorization and consent.

HIPAA Acknowledgment

I understand that protected health information (PHI) released under this authorization may be redisclosed by the recipient and may no longer be protected by federal privacy regulations. I authorize disclosure of my PHI for the purposes described herein and understand that I have the right to receive a copy of this authorization upon request.

I acknowledge and consent to the release of PHI for IME purposes under the terms above.

Attestation

I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge. I understand that knowingly providing false information may expose me to civil or criminal liability under applicable law.

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