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Division of Workers' Compensation

Other Independent Medical Examinations
 

Form

Description

Request to Erase (Redact) Medical Information from an Audio Recording

Form #WC34

MS Word Fillable PDF

This form must be used by an injured worker to request that a judge order information be erased from the audio recording taken during a medical evaluation.  The request is based on the belief that the information is private and not related to the workers’ compensation claim. 

   

IME Advisement

Form #WC36

MS Word
This form must be signed by an injured worker prior to undergoing an independent medical examination that will be audio recorded. It provides information on the injured workers’ rights and responsibilities.
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