Employee Waiver Of Examination By Personal Physician {53913}

EMPLOYEE WAIVER OF EXAMINATION BY PERSONAL PHYSICIAN State Form 53913 (4-09) INDIANA WORKER'S COMPENSATION BOARD 402 West Washington Street, Room W196 Indianapolis, IN 46204 INSTRUCTIONS: Please have claimant complete this form. Submit together with Agreement to Compensation (Form 1043). I have read the report of Dr. 20 the , dated the day of ________________, , and understand that this medical opinion states that I have a __________% permanent partial impairment of as a result of injuries sustained in the above mentioned accident. I, , understand that, pursuant to the Workers Compensation Act of Indiana, I have the right to have an examination by a qualified physician of my choice, at my own expense, for the purpose of determining what degree of permanent partial impairment, if any, I may have as a result of injuries suffered on the day of , 20 , while in the employ of . I understand that any impairment rating obtained from such an examination is not binding upon the employer or insurance carrier, although it may be taken into consideration. I do not wish to have an examination by a physician of my own choice and I hereby accept and agree with the opinion of Dr. concerning the extent of my permanent injuries as described in the attached report. I understand that this waives only my right to an examination by a physician of my own choosing regarding this particular settlement. Signed and dated this day of , 20 . X Signature of Employee American LegalNet, Inc. www.FormsWorkflow.com