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Independent Examiner s Name Date IME Authorization No. AUTHORITY OR PROPRIETOR NOR INSURANCE CARRIER OR EMPLOYER MAY CAUSE DIRECT OR ENCOURAGE A REPORT TO BE SUBMITTED AS EVIDENCE IN WORKERS COMPENSATION CLAIM ADJUDICATION WHICH DIFFERS SUBSTANTIALLY FROM THE PROFESSIONAL OPINION OF THE EXAMINING INDEPENDENT EXAMINER. SUCH AN ACTION SHALL BE CONSIDERED WITHIN THE JURISDICTION OF THE WORKERS COMPENSATION FRAUD INSPECTOR GENERAL AND MAY BE REFERRED AS A FRAUDULENT PRACTICE. IME-4 7-14 It is unlaw ...

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