Fill and Sign the Maine Workers Compensation Board Form

REQUEST FOR INDEPENDENT MEDICAL EXAMINATION MAINE WORKERS' COMPENSATION BOARD OFFICE OF MEDICAL/REHABILITATION SERVICES 27 STATE HOUSE STATION AUGUSTA, ME 04333- 0027 (207) 287- 7062 1. INSURER FILE NUMBER: 6. SOCIAL SECURITY NUMBER (last 4 digits): XXX- XX- 7. DATE OF BIRTH: 2. EMPLOYER NAME: 8. EMPLOYEE LAST NAME: 9. FIRST NAME: 10. M.I.: 3. EMPLOYER MAILING ADDRESS AND PHONE NUMBER: 11. EMPLOYEE ADDRESS -NUMBER AND STREET: 4. INSURER NAME: 12. CITY: 13. STATE: 14. ZIP: 15. HOME PHONE: 5. INSURER MAILING ADDRESS: 16. DATE OF INJURY: 17. W CB FILE NUMBER: 18. ADJUSTER NAME, PHONE AND EMAIL ADDRESS : NATURE OF INJURY:____________________________________________________________________________________________________________________________ AGREED UPON INDEPENDENT MEDICAL EXAMINER? YES NO IF YES , NAME, ADDRESS AND TELEPHONE: OF AGREED UPON EXAMINER: _____________________________________________________________________________ IF NO, HAS THERE BEEN AN UNSUCCESSFUL MEDIATION OR HAS A REQUEST FOR PROVISIONAL ORDER BEEN ACTED ON AND THE CASE IS PROCEEDING TO THE FORMAL HEARING LEVEL ? YES NO IF YES, PETITIONS PENDING:_____________________________________________________ ________________________________________________________________ $'0,1,675$7,9(/$:-8'*(:__________________________________________________________________ __________________________________________________ PREF ERRED SPECIALTY, IF ANY (NOTE:THE BOARD IS NOT BOUND BY SUCH PREFERENCE): ____________________________________________________________ QUESTIONS REL ATING TO THE MEDICAL CONDITION OF THE EMPLOYEE (ATTACH A SEPARATE SHEET OF PAPER IF NECESSARY): LIST ALL INTERESTED PARTIES AND W HOM EAC H REPRESENTS (EE OR ER) (ATTACH A SEPARATE SHEET OF PAPER IF NECESSARY) . NOTE: COPIES OF THIS DOCUMENT MUST BE MAILED OR DELIV ERED TO ALL PARTIES LISTED HERE. ER/EE:______ NAME: __________________________ CLIENT:____________________ ADDRESS: ______________________ _________ PHONE: __________________ ER/EE:______ NAME: __________________________ CLIENT:____________________ ADDRESS: ______________________ _________ PHONE: __________________ ER/EE:______ NAME: __________________________ CLIENT :____________________ ADDRESS: ______________________ _________ PHONE: __________________ ER/EE:______ NAME: __________________________ CLIENT :____________________ ADDRESS: ______________________ _________ PHONE: __________________ ER/EE:______ NAME: __________________________ CLIENT :____________________ ADDRESS: ______________________ _________ PHONE: __________________ REQUESTER NAME, ADDRESS, TELEPHONE NUMBER AND EMAIL ADDRESS: DATE MAILED: The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine W orkers’ Compensation Board. Telephone: 1- 888-801-9087 or TTY Maine Relay 711. W CB M -2 (eff. 1/1/13 UHY)