Insurers Request for Director Approval of an Independent Medical Examination - Oregon 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Worker Information section. Enter the worker's name, phone number, address, date of injury, insurer name, and claim number.
3. In the Independent Medical Examination (IME) Information section, clearly state your reasons for requesting an additional IME and specify the conditions to be evaluated. You can attach additional documentation if needed.
4. Provide the date of the last IME that evaluated this condition. Also, indicate how many IMEs the worker has attended since the claim was opened.
5. Attach copies of previous IME notification letters or list all examinations chronologically with details such as examiner names, dates, times, places, and conditions evaluated.
6. State the purpose of previous IMEs in the designated field.
7. Complete the Certification Statement by signing and dating it. Ensure you have attached all necessary documentation before submission.
8. Send a completed copy of this form along with all documents to the Workers’ Compensation Division at the specified address.

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