La. Admin. Code tit. 40 § I-6653
RETURN TO: 1. Social Security No. OFFICE OF WORKERS' COMPENSATION 2. Date of Injury/Illness _______-_________-_________ POST OFFICE BOX 94040 3. Part(s) of Body Injured_______-_________-_________ BATON ROUGE, LA 70804-9040 4. Date of Birth _______-_________-_________ (225) 342-7559 5. OWC Docket Number _________________________________________ TOLL FREE (800) 201-2494 6. OWC District Number_________________________________________ REQUEST FOR INDEPENDENT MEDICAL EXAMINATION NOTE: THIS REQUEST WILL NOT BE HONORED UNLESS A DISPUTE HAS ARISEN AS TO CONDITION OF THE EMPLOYEE AS PER L. R.S. 23:1123 7. This form is submitted by: [] Employee [] Employer [] Insurer [] TPA/Self Insurance Fund A. The choice of the medical practitioner shall be that of the Director of the Office of Workers' Compensation as per L. R. S. 23:1123. B. A cover letter outlining the conflicting medical issue(s) in dispute (reason for request) along with the conflicting medical reports must be attached to this form. C. A list of names, addresses, phone numbers and reports of all physicians/medical providers who have treated or examined the injured employee for this injury must be included. Indicate who chose each health care provider. D. A copy of this request must be mailed to all parties.
EMPLOYER / INSURER'S ATTORNEY ( circle one) 12. Name Street or Box City State ____________________________________________________ Zip Phone ( )_____________________________________________________________ ________________________ Signature of Applicant Date |
La. Admin. Code tit. 40, § I-6653