Get Wc176 Request Notification Follow Up Ime.doc

The WC176 Request Notification Follow Up Ime.doc is a vital form for users needing to request a follow-up independent medical examination. This guide will provide you with comprehensive, step-by-step instructions on how to accurately complete the form online.

Follow the steps to successfully complete the WC176 form online.

1. Press the ‘Get Form’ button to obtain the WC176 Request Notification Follow Up Ime.doc and open it in your preferred online editor.
2. Enter the WC# in the designated field to identify the case related to the request.
3. Fill in the Date of original IME Appointment using the provided date fields.
4. Provide the Claimant Name and Social Security Number (SSN) in the respective fields.
5. Indicate the IME Physician’s name in the corresponding section.
6. If known, fill in the Follow-up Appointment Date.
7. Enter the Date of Injury in the appropriate field.
8. Complete the MMI/Impairment Information section by providing the Name of the treating physician and the New MMI Date as well as the New Impairment Rating.
9. Fill out the Respondent Representative Name and their Address in the designated sections.
10. Complete the Certificate of Mailing section with the current date and list the names and addresses of all parties copied on this document.
11. Sign the form in the signature box to certify the information provided.
12. Once all sections are complete, you can save changes, download a copy, print, or share the completed form as needed.

Complete your WC176 Request Notification Follow Up Ime.doc online today to ensure timely processing.