Ime4 2026

1. Click ‘Get Form’ to open the ime4 document in the editor.
2. Begin by selecting your role as either a Physician, Podiatrist, Psychologist, or Chiropractor. Check the appropriate box at the top of the form.
3. Fill in the WCB Case Number and Carrier Case Number if known. Provide the injured person's first name, middle initial, and last name.
4. Enter the date of injury and the injured person's Social Security Number. Ensure accuracy for proper identification.
5. Complete the section for Employer and Insurance Carrier details. Include their names as required.
6. Document the date of examination and provide your address, including apartment number if applicable.
7. If applicable, state the name and registration number of the IME company under which you conducted this examination.
8. In the Results of Examination section, provide a detailed account of your findings. You may continue on additional sheets if necessary.
9. Finally, certify your report by signing it with your name, date, and address before submitting it to all required parties.

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