Get 8775330337

This guide provides clear, step-by-step instructions on how to complete the 8775330337 form online. It is designed to assist users by breaking down each section of the form to ensure accurate and efficient completion.

Follow the steps to fill out the 8775330337 form online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Identify the appropriate category by checking one of the options provided: Physician, Podiatrist, Chiropractor, or Psychologist.
3. Input the WCB Case No. and Carrier Case No. (if known) in the designated fields.
4. Enter the injured person's first name, middle initial, and last name in the corresponding fields.
5. Provide the carrier or employer details and the injured person's Social Security Number.
6. Fill in the Date of Injury or Illness, and the Date of Examination accurately.
7. Complete the address section, ensuring you list the full address including the apartment number, if applicable.
8. Record the authorization number, the date of the report of Independent Medical Examination, and the start and end time of the patient examination.
9. Detail the total time spent reviewing records in the appropriate field.
10. If you conducted the examination as an employee of an IME company, include the name and Workers' Compensation Board registration number of the IME company.
11. Attach the Report of Independent Medical Examination along with this cover sheet. Ensure that the report includes a description of the examination, a list of documents reviewed, the examiner's professional opinion, and a signed certification.
12. Review the completed form for any errors before saving, downloading, printing, or sharing the final document.

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