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NY WCB IME-3: Examiner's Report of Info Request

Section 137 of New York's Workers' Compensation Law requires an independent examiner who has performed or will perform an IME to tell the Board about any request for information regarding the claimant, and about any response. Item 10-A of the IME-3 reports a request received, with a copy attached, and item 10-B reports the examiner's response, with the response and materials supplied attached.

Who completes it

The independent medical examiner completes items 1 to 9 (examiner, requesting party, IME authorization number, IME entity registration, exam date, claimant, case number, injury date and report date) and signs 10-A, 10-B or both.

Submitting and payment

How to submit it
Mail the form with the attached request or response to the Workers' Compensation Board's centralized mailing address within ten days of receiving the request, or within ten days of sending the response.

Good to know

  • If you answer within ten days of receiving the request, complete both 10-A and 10-B on one form; otherwise file separate forms within each deadline.
  • A request limited to scheduling the IME does not need an IME-3, but a copy of Form IME-5, the claimant's notice of IME, must go to the Board.
  • Do not use the IME-3 to file records or reports that belong in the Board file; submit those at the time the IME is scheduled.
  • Independent examiners who fail to file required forms may be disciplined, including removal of their authorization to perform IMEs.

Get the official form

Download the current version from the source each time; forms change without notice.

Independent Examiner's Report of Request for Information/Response to Request Regarding Independent Medical Examination

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

When must an IME-3 be filed?

Within ten days of receiving a request for information about a claimant you have examined or will examine, including faxed or electronic requests, and within ten days of sending any response. If the response is sent within ten days of the request, one IME-3 with both 10-A and 10-B completed covers both.

Does a scheduling request require an IME-3?

No. If the request for information is limited to scheduling the independent medical examination, the IME-3 is not needed. The examiner must still send a copy of Form IME-5, the Claimant's Notice of Independent Medical Examination, to the Workers' Compensation Board.

Can records be released with an IME-3 response?

Release of medical and workers' compensation records to the Board or the requester is subject to confidentiality laws, including Section 110-a of the Workers' Compensation Law and Section 18 of the Public Health Law. The form notes that a provider retained by an employer or carrier to evaluate a workplace injury is exempt from HIPAA's disclosure restrictions.