Effective July 22, 2019
The employer/insurance carrier or an attorney representing the employer/insurance carrier must file this completed form or other response under 876 IAC Chapter 4, within 20 days of receipt of claimant's Original Notice & Petition Concerning Independent Medical Examination and serve it on the claimant.
The employer/insurance carrier uses this form to consent to pay for the reasonable expenses of the examination requested in the claimant's Petition or to refuse to pay expenses for the requested examination.
The information provided in this case will be open for public inspection under Iowa Code section 22.1.
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You must use Adobe Acrobat Reader to complete DWC forms electronically. Other PDF readers might not render the forms correctly. To get Adobe Acrobat Reader for free, click here.
- Download the 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 through 8.
- Provide your information.
- If you are an attorney representing the defendant(s), provide your information under “Signature of Attorney for Claimant.”
- If you are a representative of the employer, provide your information under “Signature of Representative of Employer.”
- Sign the form (Rule 876 IAC 4.11).
- If you are an attorney representing the defendant(s), sign on the “Signature of Attorney for Defendant(s)” line.
- If you are a representative of the employer, sign on the “Signature of Representative of Employer” line.
- Serve a copy to the claimant or claimant’s attorney (Rule 876 IAC 4.13).
To download a PDF version of the instructions, click here.
The Iowa Division of Workers' Compensation (DWC) is implementing mandatory eFiling on the Workers' Compensation Electronic System (WCES) in contested case proceedings effective July 22, 2019.
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.