This form must be submitted when the claimant previously had a Division IME and was determined to be ‘not at MMI,’ and the insurer/respondent is now requesting a follow-up IME. Per Rule 11, to the extent possible the follow-up IME will be held with the original IME physician. If the original physician is unable to perform the follow-up, please notify the Division’s IME Unit. The requesting party is responsible for payment, and also “shall pay any additional examination expense” as set forth in the Rule. If this follow-up is on a reopened claim, the facts of the specific case may determine the party responsible for requesting and paying for the exam. Do not submit this form if the follow-up is for repeat range of motion only; please notify the Division of the date and time of the appointment.