Provider Account Application - Independent Medical Examiner (IME)


Provider Account Application - Independent Medical Examiner (IME)

Document Information
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Title	Provider Account Application - Independent Medical Examiner (IME) (A fillable form - 575 KB PDF)
Description	In order to do independent medical exams a provider must obtain a provider account number with L&I. This packet includes the application and agreement with instructions, IME Provider Exam sites form (F245-047-000) and Request for Taxpayer ID and Certification - Form W-9 (F248-036-000) (8 pages).
Detail
Form number	F245-046-000
Availability	Online only
Keywords	application, doctor, exams, form W-9, IME, independent medical examiner, independent medical exams, medical, most requested forms, physician, provider application, taxpayer
Languages	English
Valid dates	04-2007
Contact information	Claims for Job Injuries Treating Injured Workers
Related information
Documents	Independent Medical Examination (IME) Provider Exam Sites Request for Taxpayer ID - Form W-9 Provider Accounts
Web pages	For Medical Providers