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NY WCB IME-4: Report of Independent Medical Exam

Every independent medical examination report in a New York workers' compensation case starts with the IME-4 cover sheet. It identifies the examiner's profession, who requested the exam, the claimant, carrier, Board authorization number, exam start and end times, total record review time and any IME company involved, and carries the mandatory certification. The narrative report and any IME-4.3A or IME-4.3B attachments follow it.

Who completes it

The Board-authorized independent medical examiner, a physician, psychologist, podiatrist or chiropractor, completes the cover sheet, attaches the narrative, and signs and dates the certification. Claimant questionnaires or intake sheets are attached as well.

Submitting and payment

How to submit it
Submit copies the same day and in the same manner to the Workers' Compensation Board, the carrier or self-insured employer, the claimant's attending physician or other attending examiner, the claimant's representative, and the claimant.

Good to know

  • The narrative must describe the exam, list every document or piece of information reviewed, give the examiner's opinion, and end with the exact certification wording, signed and dated below it.
  • A report that does not substantially comply with 12 NYCRR 300.2(d) may be precluded from consideration as evidence.
  • If the exam finds schedule loss of use or non-schedule permanent partial disability, include IME-4.3A and/or IME-4.3B with the cover sheet.
  • If the examiner worked for or under contract with an IME company, give its name and Board registration number.

Get the official form

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

Independent Examiner's Report of 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

What certification must an IME report in New York include?

The IME-4 prints the required wording: the report is a full and truthful representation of the examiner's professional opinion; no person or entity caused, directed or encouraged a report differing substantially from that opinion; and the examiner reviewed the report and attests to its accuracy. The signature and date must appear below it.

Who receives a copy of the IME-4 report?

The Board, the insurance carrier or self-insured employer, the claimant's attending physician or other attending independent examiner, the claimant's representative if any, and the claimant. All copies must be submitted on the same day and in the same manner.

Do claimant questionnaires go with the IME-4?

Yes. Any questionnaire or intake sheet completed by the claimant before or after arriving for the examination must be attached to the cover sheet with the report. By certifying on the cover sheet, the examiner certifies the entire contents of the report of independent medical examination.