Healthcare IME Document

HEALTHCARE INDEPENDENT MEDICAL EXAMINATION (IME) AUTHORIZATION

Patient Name:   Date of Birth:   Gender:

Patient Information

Insurance Information

Medical History — Summary

IME Request Details

Requested Examination Components (check applicable):
Musculoskeletal examination    Neurological examination    Psychological evaluation
Functional capacity evaluation    Imaging review / radiology interpretation    Other (specify below)

Records to Be Provided

The undersigned authorizes release of the following records to the appointed IME examiner and requesting party:
Office/clinic notes    Imaging and radiology reports    Laboratory and diagnostic test results
Medication lists and pharmacy records    Employer records related to injury/illness    Other (describe)

Authorization and Consent

By signing below, I authorize the performance of an Independent Medical Examination as described above. I understand that the IME is conducted at the request of a third party for evaluation, utilization review, or adjudication and is not for purposes of treatment. I consent to a physical examination, review of medical records, and appropriate testing as reasonably required by the examiner.

I expressly authorize release of my protected health information, as described in this document, to the IME examiner, the referring party, and any entity that requires the information for claim review or case management. I understand that information disclosed pursuant to this authorization may be redisclosed by the recipient and may no longer be protected under privacy rules.

I acknowledge that I may withdraw this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on it. This authorization will expire on the date specified below or, if no date is specified, 12 months from the date of signature.

I consent to the examination and evaluation described above.    I authorize release of my medical records as indicated.    I consent to audio and/or video recording of the IME when deemed necessary by the examiner.

HIPAA Authorization

I authorize the use and disclosure of my individually identifiable health information as necessary for the IME and related claim activities. The information to be disclosed includes medical history, diagnostic test results, office notes, imaging, and related employment or disability records necessary to fulfill the IME request. I understand that the information may be collected, used, and disclosed by the recipient for the evaluation of my condition and for claim resolution.

I understand I may revoke this authorization in writing at any time, except where disclosures have already been made in reliance on this authorization. I acknowledge that treatment, payment, enrollment, or eligibility for benefits is not conditioned on signing this authorization where prohibited by law.

I acknowledge and authorize the HIPAA release above.

Acknowledgment and Certification

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that the IME findings will be documented in a written report that may be provided to the referring party and other authorized entities. I understand that the IME is evaluative and that I should seek continued care from my treating providers as appropriate.

I understand that I am responsible for arriving at the scheduled IME location on time and that failure to appear may result in administrative fees or a rescheduling at the requesting party's discretion. I further understand that this authorization does not obligate any provider to provide future treatment.

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