Health Care Provider's Application for Authorization (Form MR-IME-1)
Submit your application directly to the medical society in the county in which you practice. A list including contact information for each county medical society can be viewed at the New York State Medical Society's web site . Osteopathic physicians have the option of submitting their applications to the New York State Osteopathic Medical Society .
Please do not send your original application directly to the Workers' Compensation Board. Any original applications received will be returned. Be advised that the medical society to which you submit your application may charge a fee to process your application. Applicants for authorization to perform independent medical examinations must include a certificate from a specialty board recognized by the American Board of Medical Specialties or the American Osteopathic Association .
Submit your application directly to: New York State Workers' Compensation Board, Medical Director's Office, 150 Broadway, Suite 195, Menands, New York, 12204. Include a current curriculum vitae. Podiatrists must also include a certificate showing that they have completed an approved residency program.
All practice addresses must be registered with the New York State Education Department before your application can be processed. You can reach the Education Department at (518) 474-3817, extension 410. Complete every question on the application which applies to you. All applicants are encouraged to provide a current home address and home telephone number (information which will not be shared with the public). This information may be required in the event we need to reach providers directly regarding administrative matters. Please sign your application in original ink.
If you have any questions about the application process, please call the Medical Director's Office at (800) 781-2362, or send an e-mail to firstname.lastname@example.org.