Fill and Sign the Instructions 1 Complete All Applicable Sections of This Form

SECOND INDEPENDENT MEDICAL EVALUATION (SIME) FORM INSTRUCTIONS: (1) Complete all applicable sections of this form ON BOT\ H SIDES, (2) list the specifics which reflect the SIME dispute in colu\ mns four and seven, (3) file this form and one copy of the medical reports reflecting the medical dispute with the appr\ opriate Board office in accordance with 8 AAC 45.072 and (4) file a Re\ quest for Conference form. If this form is not signed by all parties, the party preparing this form must serve a copy o\ f this form and the attachments upon all other parties in accordance wit\ h 8 AAC 45.060. Employee's Name: Employer's Name: Date of Injury: AWCB Case Number: Body Parts in Dispute: Attending Physician(s) Names: 1. 2. 3. Employer Independent Medical Evaluation (EIME) Physician(s) Names: 1. 2. 3. 1 Dispute(s) / Issue(s) 2 Phy No. 3 Report Date 4 Medical Opinion (include report page and item/paragraph #) 5 Phy No. 6 Report Date 7 Medical Opinion (include report page and item/paragraph #) Causation: Compensability: Treatment (List disputed time periods in Col 4 & 7) Degree of Impairment (State the percent of impairment in Col 4 & 7) Functional Capacity (Attach job description) Medical Stability (List disputed time periods in Col 4 & 7) CONTINUED ON BACK Form 07-6147 (Rev 02/2010) SECOND INDEPENDENT MEDICAL EVALUATION (SIME) FORM (Continued from Fro\ nt) 1 Dispute(s) / Issue(s) 2 Phy No. 3 Report Date 4 Medical Opinion (include report page and item/paragraph #) 5 Phy No. 6 Report Date 7 Medical Opinion (include report page and item/paragraph #) Ability to Enter a Reemployment Plan (Attach plan) Non-SIME Issues(s) (AS 23.30.110 (g) request) What medical speciality is required for the SIME? Please indicate if the parties have stipulated to a speciality? SIME phy\ sician? If yes, list the speciality(ies) and/or physician(s): Has the employee been seen by any physicians on the Board's SIME list of\ examiners or at any facility where the SIME physicians practice? If yes\ , list the physicians. The Board's list of examiners can be obtained at www.labor.alaska.gov/wc or by contacting the Division at (907) 269-4980 Anchorage, (907) 45\ 1-2889 Fairbanks or (907) 465-2790 Juneau. Has the employer used any physicians on the SIME list or the practice at\ which the SIME physicians treat during the past 12 months? If yes, list\ the physicians. IF THERE IS NO ACTIVE APPLICATION OR PETITION IN THIS CASE, THE PARTY PR\ EPARING THIS FORM MUST ATTACH AN APPLICATION OR PETITION TO COMMENCE PRO\ CEEDINGS. Signature(s) Employee or Representative Employer, Insurer or RepresentativeEmployee Employer (Each party must check applicable boxes. If the parties agree on any s\ tatement below, it constitutes a stipulation under 8 AAC 45.050.) Based upon the above information, an SIME dispute exists under AS 23.30.\ 095(k). The right to have the board determine the need for an SIME is waived. A workers' compensation offi\ cer or the board designee may decide whether or not to order an SIME. Non-SIME issues, noted above, should be submitted to the board's examine\ r under AS 23.30.110(g). The right to have the board require an examination is waived. A workers' compensation officer or the board's designee may decide whether or not to order an ex\ amination, in conjunction with an SIME, under AS 23.30.110(g). The\ employer will pay for the cost of this examination. An examination by the board's examiner is considered to be\ an SIME. No subsequent SIME will be ordered on the non-SIME issues not\ ed above. This form amends the issues in an active application or petition previou\ sly filed by a party. The requirement to serve and file an answer to th\ e application or petition as amended by this SIME form, is waived. Date Date Form 07-6147 (Rev 02/2010)