Independent medical examiner provider details

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

Oct 2019

Reading level

medium

File Type and Size

PDF, 99.8 kB

Document Length

3 pages

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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