Form 100A (14-0007A) — Answer Concerning Independent Medical Examination (IME)

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Name

Answer Concerning Independent Medical Examination (IME)

Number

100A (14-0007A)

Effective

July 1, 2023

Overview

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.

Instructions

1. 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.
2. 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).
3. Fill out paragraphs 1 through 8.
4. Provide your information under the signature for the attorney representing defendant(s) or represenative of defendant(s).
5. Sign the form electronically on the fillable PDF or by hand after printing out the completed form.
6. Complete and sign the Proof of Service.
7. 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.
8. Electronically file (eFile) the completed and signed answer on the Workers' Compensation Electronic System (WCES), which will serve claimant.

EFILING ON WCES

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.