Becoming an IME Provider
 
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  1. You must fill out an application:
  2. On the application first check the boxes in the upper right-hand corner to tell us how you want your account set up. Either as a:
    1. Firm/firm affiliated provider (See pg 76, Medical Examiners' Handbook
      (F252-001-000)), or
    2. Individual Examiner (If you have a provider number, you still need a unique IME number.) and if you plan to conduct IMEs either:
    3. In Washington state, or
    4. Out-of-state.

The table below should assist you in filling out the form according to how you are applying.

IME Provider Account Application form
Form/SectionIndividual ExaminerExaminer affiliated with a firmFirm only
Section I & W-9 formExaminer Tax IDFirm Tax IDFirm Tax ID
Section II AExaminer infoFirm infoFirm info
Section II B-CExaminer infoExaminer infoDo not fill out
Medical QualificationsExaminer infoExaminer infoDo not fill out
IME Provider Exam Sites formList up to 4 sites where you regularly conducts IMEs.List up to 4 sites where you conduct IMEs for the firm.List all locations where IMEs will be conducted by examiners affiliated with your firm.
Statement of AgreementExaminer signs and datesExaminer signs and datesFirm signs and dates


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