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How to use or fill out the Independent Medical Exam form online
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Click ‘Get Form’ to open the Independent Medical Exam (IME) Travel and Wage Reimbursement Request in our editor.
Begin by filling out your personal information in the 'Worker Information' section, including your claim number, name, date of injury, and contact details.
In the 'Travel Information' section, enter the date of each trip, travel code, cities traveled from and to, roundtrip mileage, and expense costs. Ensure you provide one entry per line for clarity.
If applicable, complete the 'Reimbursing Wages' section by detailing any time missed from work due to attending the IME and your hourly wage at that time.
Finally, sign the form to confirm that all information is accurate and submit it along with any required receipts within one year of your exam.
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