Multiple Specialty Requested
I. Requested By
Name     Company  
Phone     Ext  
Address     City  
State     Zip  
Fax     Email  

II. Type of Review Requested
Independent Medical Examination Jurisdiction of Exam  
Early Assessment    
Re-evaluation    
Functional Capacity Evaluation
Worker's Compensation Case
Disability
Specialty Requested:
Other (Please Specify)

III. Claimant Information
Last Name First Name
Address City
State Zip
SSN DOB
Home Phone Work Ph  
Minor? No Gender  
Special Needs of Examinee:

IV. Injury Information
Date of Loss: Claim #    
Injury Claimed (Include body part and CPT codes if available)  
 Type of Claim:
 
 Other (Please Specify)

V. Treating Provider
Name Address
City State
Zip Phone
Fax Specialty

VI. Claimant's Attorney
Name   Law Firm      
Address   City      
State   Zip      
Phone   Fax      
 

VII. Please Have Independent Examiner Address the following issues:

Diagnosis?
Prognosis?
Causation of injury
Preexisting injuries
Further treatment reasonable, related, necessary?
Further diagnostic testing necessary?
Prior diagnostic testing reasonable and necessary?
Prior treatment reasonable, related, & necessary?
Any restrictions (work / daily living)?
Preaccident status reached?
Disability rating?
Other issues to be addressed (including additional information regarding loss)

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