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Independent Medical Evaluation Request Form *Note: All fields are required Adjuster Information Date of request: / / Claim #: Re-Examination: Company Name: Adjuster Name: Telephone: Fax: Email Address: Address: Insured: Address: WCB#: Claimant Information Claimant Name: Telephone: Address: Occupation: Date of injury: / / Nature of injury: Social Security #: / / Date of birth: / / Attorney: YesNo Treating Physician Treating Physician: Telephone: Address: Attorney Information Attorney: Telephone: Address: Type of Examination File review onlyOrthopedicChiropracticNeurologistPM&R Other Diagnosis/PrognosisDegree of disibilityHistory of injury & treatmentMG-2 Causal relationshipFurther treatment?Apportionment PermanencySLUMMI? Return to work?Light Duty?M&S (15-8) Comments: Type of Claim GLNFWCBIOther Jurisdiction: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Copy report to: AttorneyAttending MDOther