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Original Notice & Petition Concerning Independent Medical Examination (IME)
July 22, 2019
An attorney representing the claimant or a self-represented claimant must file this completed form to apply for an order granting the claimant an independent medical examination under Iowa Code section 85.39.
Attach to this form a copy of the physician's report which evaluates the claimant's permanent disability to support the Petition.
The information provided in this case will be open for public inspection under Iowa Code section 22.1.
- Download the fill-able PDF form by clicking on the link above. Complete the form by typing the information into the fill-able fields on the PDF or by printing the form and handwriting in print the information on the printed form.
- Complete the caption by providing in the corresponding blank the:
- Name of the claimant
- Name of the employer
- Name of any insurance carrier
- Name(s) of any other defendant(s)
- Any agency file number(s)
- NOTE: In some cases, there is not an insurance carrier (e.g., when the employer is self-insured) or any other defendant(s).
- Complete the Petition by filling out paragraphs 1, 2, 3, 4, 5, 6, 10, and 11.
- Provide your information.
- If you are an attorney representing the claimant, provide your information under “Signature of Attorney for Claimant.”
- If you are a self-represented claimant, provide your information under “Signature of Self-Represented Claimant.”
- Sign the form (Rule 876 IAC 4.11).
- If you are an attorney representing the claimant, sign on the “Signature of Attorney for Claimant” line.
- If you are a self-represented claimant, sign on the “Signature of Self-Represented Claimant” line.
- If you use an electronic signature under agency rules, lock or "flatten" the PDF document after completing the form fields to ensure the document can be viewed on all devices and to prevent other users from manipulating or editing the information.
- Attach the physician's report which supports the Petition.
- Deliver a completed copy of the form to the employer by certified mail, return receipt requested, or by personal service as in civil actions (Rule 876 IAC 4.7) and mail a copy to the employer’s attorney of record for this file, if known (Rule 876 IAC 4.13).
- Complete the proof of service portion on the original of this form and file the completed form, with the physician's report.
To download a PDF version of these instructions, click here.
EFILING ON WCES
The Iowa Division of Workers' Compensation (DWC) requires parties and attorneys to electronically file (eFile) documents on the Workers' Compensation Electronic System (WCES) in contested case proceedings.
You must eFile on WCES documents, such as this completed form, unless the DWC has granted you an eFiling exception.
For more information about eFiling, click here.