CLAIMANT'S ADDRESS 8. EXAMINATION TIME, DATE, AND PURPOSE OF EXAMINATION 9. EXAMINATION PREMISE 10. EXAMINATION QUESTION 11. EXAMINATION ENDS 12. QUESTIONS ADD TO FORM 13. ADDRESS AND PHONE NUMBER OF PARTY REQUESTING INFORMATION 14. INFORMATION ON PARTY CONTACT INFORMATION ON PARTY REQUESTING INFORMATION 15. PARTY REQUESTED INFORMATION (If Applicable) 16. MEDICAL EXAMINATION QUESTION 17. MEDICAL EXAMINATION ANSWER 18. EXAMINATION CLARIFICATION (If Applicable) 19. REQUEST FOR MEDICAL EXAMINATION ANSWER 20. REMARKS OF PARTY REQUESTING INFORMATION 21. RESPONSE TO INFORMATION QUESTION BY PARTY 22. DISCLOSURE BY PARTY 23. CONCLUSION OF EXAMINATION 24. STATEMENT FROM PARTY REQUESTING INFORMATION IN BUNDLE FORMAT A. EXAMINATION QUESTIONNAIRE B. EXAMINATION ANSWER C. PARTY REQUESTED INFORMATION A. MEDICAL EXAMINATION QUESTIONNAIRE PARTY REQUESTING INFORMATION A. QUESTIONS AFFIRM STATEMENTS 24 B. QUESTIONS DISPUTED 25 C. MEDICAL EXAMINATION ANSWER C. PARTY REQUESTED INFORMATION C. QUESTIONS AFFIRM Statements 26 D. OTHER ANSWER 27. INITIAL DATE OF BOTH REQUEST AND RECONFIRMATION OF REQUEST. 28 D. BILL OF HEARING DATE 28.1 INITIAL COURT DATE OF HEARING. 29 METHOD OF REFUNDS DATE/TIME/DATE OF PAYMENT. 10. RECONFIRMATION OF RECALL. 4. RECALL EXAMINATION PROCEDURE AND RULE OF CONSTRUCTION. 30. MEDICAL EXAMINATION INITIATION. 3. QUESTIONS FOR REVIEW.
NY IME-3 2014-2024 free printable template
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NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205 State of New York WORKERS' COMPENSATION BOARD INDEPENDENT EXAMINER'S REPORT OF REQUEST FOR INFORMATION/RESPONSE
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