IME Provider Application Please complete the application below to start the vetting process to becoming an IME Provider. Question Title * 1. Do you have experience in performing IME's? Yes No Comment(s) Question Title * 2. What is your Name? Question Title * 3. What is your Phone Number? Question Title * 4. What is your Fax Number? Question Title * 5. What is your Email address? Question Title * 6. Do you have a Specialty? (i.e. Ortho, Neuro, etc.) Question Title * 7. Location(s) where you would perform IME’s? Question Title * 8. Do you provide ratings using the Fourth Edition? Yes No Other (please specify) Question Title * 9. Area(s) of expertise? Question Title * 10. State license # Question Title * 11. Are you Board Certified? Yes No Other (please specify) Question Title * 12. Are you fluent in other languages besides English? If yes, please list languages below. Done