Invasive Medical Procedure Authorization {3227}

Invasive Medical Procedure Authorization Autorizati n para Procedimiento M dico Invasivo Workers Compensation Division Workers name: Date of injury: Insurers name: Insurers claim number: Insurer medical examination (IME) physician: Complete this section Proposed invasive procedure/Procedimiento invasivo propuesto: IME physicians name: Examination date: Address: Phone: X IME physicians signature Date Worker: Complete this section (Trabajador: Complete esta secci n)
YES. I consent to the proposed invasive procedure described above. (S, estoy de acuerdo con el procedimiento invasivo propuesto descrito previamente.) 
NO. I decline the proposed invasive procedure described above. I understand that my workers compensation benefits cannot be suspended if I say no. (NO, no estoy de acuerdo con el procedimiento invasivo propuesto descrito previamente. Tengo entendido que mis beneficios de compensacin para trabajadores no podrn ser suspendidos si digo que no.) X Workers signature (firma del trabajador) Date (fecha) Physician: Make copies of this form for the worker and your records; send the original to the insurer. 3227 440-3227 (3/99/DCBS/WCD/WEB