Info Regarding Independent Medical Exam {WC036}

I understand that I will be going to an independent medical examination (IME).I understand that the IME will be done by a doctor who is not giving me treatment or care,and that I will not have a patient/doctor relationship with this doctor. The doctor doingtheIME is being paid by the employer or the in my workers222 compensation claim.Thedoctor will write a report about the exam, and I will get a copy of the report.I understand that the doctor will ask me questions about my condition and/or medicalhistory, and may also look at my medical records.I understand that the doctor is required by law to make an audio (voice) recording of thisexamination. Therefore, what the doctor says and what I say may be heard by others at alater date and I should not have an expectation of privacy about things that are related tomy workers222 compensation claim.I understand that anyone involved in my claim, including me, can request a copy of therecording, and that if anybody makes a request the recording will first be given to me. Iunderstand that if I say something during the examination that I believe is private and notrelated to my claim, there is a way for me to try to have that part of the recording erased.I understand that I have 20 days after the report is sent to me to ask, in writing, for a copyof the audio recording. If I believe that part of the recording should beerased, Ihave to say it in writingwithin 15 days of when the recording was sent to me. Iunderstandthat information aboutthe process is available by contacting the Division ofWorkers222Compensation and/orlooking at its website. Anything that is mentioned in thedoctor222swritten report will notbe erased.I understand that I must be given this form, and that I must sign this form, according to aDivision of Workers222 Compensation Rule. I understand that refusing to sign this formmaybe determined to be a refusal to submit to an independent medical examination, andthatsuch refusal could possibly impact my receipt of benefits.I understand that this form is intended to provide specific and limited informationregardingthe IME. I can seek additional information and/or legal advice if I so choose. Ican alsocall the Division at 303-318-8700 or 888-390-7936 for additional informationregardingRule 8 requirements. Signature Print name Date For use by a language interpreter, if necessary I, (print name of interpreter) affirm that on this day of , 20, I read this document in its entirety to the individual whose name appears above in that person222s native language, and that the person indicated an understanding of each and every provision contained on this form. Signature American LegalNet, Inc. www.FormsWorkFlow.com