Ologist q Initial Authorization q Reinstatement q Change in Rating (Physician only) THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION 1-800-781-2362 HEALTH PROVIDER'S APPLICATION FOR AUTHORIZATION UNDER THE WORKERS' COMPENSATION LAW IMPORTANT INSTRUCTIONS TO HEALTH PROVIDERS Complete both sides of this application. Do not fill in shaded area. All entries are to be typewritten or printed clearly. Illegible applications will be returned to the applicant. Physicians.
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How to fill out the NY MR/IME-1 online
The NY MR/IME-1 form is essential for health providers seeking authorization to render care under the Workers' Compensation Law. This guide will support you in accurately completing the form online, ensuring compliance with the requirements set forth by the Workers' Compensation Board.
Follow the steps to complete the NY MR/IME-1 online.
- Click the ‘Get Form’ button to access the NY MR/IME-1 form and open it in the editor.
- Select the appropriate health provider category by checking one of the following options: Physician, Podiatrist, Chiropractor, or Psychologist.
- Indicate the type of application by checking the relevant box: Initial Authorization, Reinstatement, or Change in Rating (for Physicians only).
- Complete your personal details, including your name, date of birth, home address, county, and home telephone number.
- Provide your New York State Professional License Number and the date your license was granted.
- List all office addresses where you practice in New York State. Ensure each address is accompanied by a valid registration certificate from the New York State Education Department.
- Detail your major hospital affiliations, including the name of the hospital, zip code, clinical service, positions held, and relevant dates.
- List your current professional society memberships and any board certifications you hold.
- For psychologists, podiatrists, and chiropractors, attach your curriculum vitae, detailing your academic training, supervision, and experience.
- Answer the questions regarding residency completion, authorization history, disciplinary actions, and language accommodations.
- Carefully review all entries for accuracy. Once completed, you can save changes, download the form, print it, or share it as necessary.
Complete your NY MR/IME-1 application online today to ensure timely processing.
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