Imc Form 1002 – Fill Out and Use This PDF

Department of Industrial Relations, Industrial Medical Council, PO Box 8888, San Francisco, CA 94128• (650) 737-2767

		1. Employee Name (First, Middle, Last)		2. Social Sec No.(Optional)		3. Date of Injury (Mo/ Dy /Yr)
Employee
		4. Street Address	City	Zip		5. Telephone
	Claims	6. Name :
	Administrator/
	Employer	7. Street Address	City	Zip		8. Telephone
	Exam`	9. Date of Appointment Call	10. Date of Initial Examination		11. Date of Referral for MedicalTesting/Consultation
	Referral
	Schedule
		12. Date AME/QME's Report Served on all Parties
	Disputed	13. The following medical issues will be used to determine the patient's eligibility for workers' compensation. Check
	Medical	the appropriate box and reference the corresponding page(s) or section of the med-legal report for details.
	Issues
	And Conclusion				Report page(s)
					or section					Pending or
						Yes	No			Info. Not Sent
		a. Is there permanent disability?			_____
		b. Is the medical condition stable and not likely			_____
		to improve with active medical or surgical treatment
		(i.e., is the condition permanent and stationary)?

If restricted work is recommended, reference page(s)/section in report for details:_______________

Basis for	Check box and refer to page(s) or section in report.	Report page(s)						Pending or
Conclusions		or section			Yes		No	Info. Not Sent
	14. Are there subjective complaints?	_____
	15. Are there any abnormal physical or psychological	_____
	examination findings?
	16. Are there any relevant diagnostic test results (x-ray/laboratory)?	_____
	17. What are the diagnoses? (List) ___________________________________________________________________
	_________________________________________________________________________________________________
	18. Were treating physician's reports reviewed?	_____
	19. Were other physicians consulted?	_____		Yes		No

QME

20.Signature ______________________________________________________________Date:____________________

21.Name _________________________________________________Specialty_________________________________

22.Street Address_________________________________City ___________________________ Zip _______________

23.Telephone ____________________________________________Cal. # ____________________________________

______________________________________________________________________________________________________________

IMC FORM 1002 (Rev. 12/95)

Department of Industrial Relations, Industrial Medical Council, PO Box 8888, San Francisco, CA 94128 •(650) 737-2767

Instructions

To the QME or AME: You are required by Labor Code sections 4060, 4061, and 4062 to summarize the medical findings from your comprehensive medical-legal evaluation on the form prescribed by the Industrial Medical Council (IMC). Please complete the form in its entirety.

Employee Information: Fill in employee's full name, address, telephone number and date of injury .

Exam Referral Schedule: complete dates that patient called for an appointment, date of initial examination, date referred for consultation(s), if any, and date report served on all parties. Supplying these dates are a legal requirement.

Disputed Medical Issues and Conclusions: Complete this section by checking appropriate box and stating what page(s) or section of the medical legal report contain the narrative for details. If diagnostic or laboratory tests have been ordered and the results or a medical records request is pending, check that box. If you cannot render opinions because of pending information, please complete and serve the report to comply with the 30 day time requirement and state what issues could not be evaluated.

Basis for Conclusions: Check appropriate box and give page numbers or section where the narrative in the full report is found. For diagnoses, in addition to page numbers, please briefly summarize the diagnoses in lay terms where possible. Also, list name and specialty for other physicians who provided information used in the medical legal report.

Signature: Remember under the Labor Code, all your reports must be signed under the penalty of perjury.

You are required to serve the medical legal report and this form on the employee, the claims administrator, (if none, employer) and the Disability Evaluation Unit (DEU) having jurisdiction over the employee's area of residence.

Authority cited: Sections 139, 139.2, 4061 and 4062, Labor Code.

Reference: Sections 139.2, 4061 and 4062, Labor Code.