Medical Expense Management :: Services - Online Forms

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: Yes

Treating Physician

Treating Physician:

Telephone:
Address:

Attorney Information

Attorney:

Telephone:
Address:

Type of Examination

File review only

Orthopedic

Chiropractic

Neurologist

PM&R
Other

Diagnosis/Prognosis

Degree of disibility

History of injury & treatment
Causal relationship

Further treatment?

Apportionment
Permanency

SLU

MMI?
Return to work?

Light Duty?

M&S (15-8)

Comments:

Type of Claim

Other

Copy report to: Attorney

Attending MD

Other