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