Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 3 - Hearing Rules › Chapter 66 - Miscellaneous › Subchapter E - Forms › Section I-6653 - Request for Independent Medical Examination ; Form LDOL-WC-1015

Current through Register Vol. 50, No. 6, June 20, 2024
RETURN TO: 1. Social Security No.
OFFICE OF WORKERS' COMPENSATION 2. Date of
								  Injury/Illness _______-_________-_________
POST OFFICE BOX 94040 3. Part(s) of Body
								  Injured_______-_________-_________
BATON ROUGE, LA 70804-9040 4. Date of Birth
								  _______-_________-_________
(225) 342-7559 5. OWC Docket Number
								  _________________________________________
TOLL FREE (800) 201-2494 6. OWC District
								  Number_________________________________________
REQUEST FOR INDEPENDENT MEDICAL
								  EXAMINATION
NOTE: THIS REQUEST WILL NOT BE HONORED
UNLESS A DISPUTE HAS ARISEN AS TO
CONDITION OF THE EMPLOYEE AS PER L.
								  R.S.
								  23:1123
7. This form is submitted by:
[] Employee [] Employer [] Insurer [] TPA/Self
								  Insurance Fund
A. The choice of the medical practitioner shall
								  be that of the Director of the Office of Workers' Compensation as per L. R. S.
								  23:1123.
B. A cover letter outlining the conflicting
								  medical issue(s) in dispute (reason for request) along with the conflicting
								  medical reports must be attached to this form.
C. A list of names, addresses, phone numbers and
								  reports of all physicians/medical providers who have treated or examined the
								  injured employee for this injury must be included. Indicate who chose each
								  health care provider.
D. A copy of this request must be mailed to all
								  parties.
EMPLOYEE
EMPLOYEE'S ATTORNEY
8 Name
											 ______________________________________________________
9. Name
											 ______________________________________________________
Street or Box
											 ________________________________________________
Street or Box
											 ________________________________________________
City
											 ________________________________________________________
City_______________________________________________________
State_________________________________________ Zip___________
State_________________________________________ Zip___________
Phone (
											 )__________________________________________________
Phone (
											 )________________________________________________
EMPLOYER
INSURER/ADMINISTRATOR
(circle one)
10. Name
											 ______________________________________________________
11. Name
											 ______________________________________________________
Attn:
											 ______________________________________________________
Attn:
											 ______________________________________________________
Street or Box
											 ________________________________________________
Street or Box
											 ________________________________________________
City
											 _______________________________________________________
City
											 _______________________________________________________
State_________________________________________ Zip___________
State_________________________________________ Zip___________
Phone (
											 )________________________________________________
Phone (
											 )________________________________________________
EMPLOYER / INSURER'S ATTORNEY
( circle one)
12. Name
Street or Box
City
State
								  ____________________________________________________ Zip
Phone (
								  )_____________________________________________________________
________________________
Signature of Applicant Date
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						23:1310.1.