Independent medical examiner provider details

Independent Medical Examiners (IMEs) can use this form to register or update their details with WorkSafe.

Published: 19 Jun 2020
File type: PDF
File size: 100.3 kB
Length: 3 pages
Reading level: Medium

What it contains

Information to be completed in the form includes:

  • Personal details
  • Contact Details
  • Billing Details
  • New Provider Location Address
  • Ceasing Provider Location Address

Important note: To update billing details only please use the Service provider electronic funds transfer (EFT) application form.

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