I understand that I am here for an Independent Medical or Impairment Examination (IME). This means the doctor performing the examination is neither treating me nor is an employee of whomever requested the IME (insurance company, third party adjustor, attorney, government agency, employer, or physician). The purpose of the IME is to provide a thorough objective evaluations of the specific conditions related to the injury or illness in question, as well as prior or subsequent conditions that may affect it, and answer whatever question the requesting party has. This document outlines the IME process, my rights, and my responsibilities. This IME is not a composite medical examination, it will not provide evidence of treatment or substitute for evaluation by my regular treating doctor. A patient-physician relationship is not established between the evaluating physician and me. Currently, there is no
patient privilege associated with this evaluation. Usually, a written report would be prepared, summarized in two days, and sent to the requesting party. If I would like a copy of the report, I will contact them.

I understand that generally my evaluation will begin with the doctor obtaining a history of how my problem began, and what evaluation or treatment has been rendered since, utilizing information provided verbally, on this document, in history forms, as well as that contained within whatever records may be available for review. The doctor will then ask about my current symptoms and generally record a relatively brief past medical history, and other information such as my work status, etc. All information provided may be included in the report. After the interview, a physical examination of the relevant body part will be conducted. I understand that I may need to perform a maneuver that may exacerbate my symptoms and will need to inform my examiner that what he or she is doing is causing excessive discomfort so it can be stopped right away. Some pain, stiffness, or other symptoms are produced in
most physical examinations of this sort, for help in understanding my condition. The IME, however, is not intended to cause injury or excessive pain. I understand that in order to avoid that, I must fulfill my responsibility to inform the doctors if there is something I can't do, or if a certain test is causing too much discomfort, etc.

I understand that I am permitted to have a chaperone present during the physical examination, at my request. I consent to taking the digital photography to document findings during this physical examination.

I have read and understand the affirmation and instructions. I authorize the physician or examiner to obtain any information that may be relevant to the condition in question, and to release the information and results of the IME, (verbally or in writing) to the entity that has requested the IME.
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