This cover sheet, filled out by the moving party and signed by counsel, shall be filed with the Administrative Judge at the start of the conference. Copies need to be provided to all parties.

All Medical documents for the Impartial Physician must be submitted in an electronic format or CD for (PDF, bookmarked and text recognized) on or before the date of the scheduled Conference proceeding.

Any additional medical documents that were not part of the Conference packet will only be accepted and forwarded if received by the  Department at least fifteen (15) business days prior to the scheduled impartial medical examination. Any additional medical documents received within in fifteen (15) days of the examination will only be accepted at the discretion of the Administrative Judge and the Senior Judge.

All non-medical documents must be submitted in an electronic format or CD form (PDF, bookmarked and text recognized) on or before the date of the scheduled Conference proceeding.

Please note that the actual hard copy, tabbed and index documents that are submitted  to the Administrative Judge are solely for the Judge's review and the Judge's copy will not be submitted to the impartial physician.

Print Form 140  pdf format of form-140.pdf
- Updated 7/2015