Independent Medical Exam

Claimant Name*: Phone:

Street Address:

City: State: Zip:

Date of Injury*: Claim # :

Policy Holder:

Policy #:

Claimant's Attorney*: Phone*:

Firm*: Street Address*:

City*: State*: Zip:

Insurance Carrier or client name*: Phone:

Street Address:

City: State: Zip:

Claims Examiner Name: C/E Phone

Case in Suit/Def. Atty. Name*: Case in Suit same as Carrier or Client

Tel #*: Street Address*:

City*: State*: Zip*:

Attorney's file number:

Whom to Invoice* Defense Atty Carrier or Client

Where to Send Copy of Request* Defense Atty Carrier or Client Both

Type(s) of Exam(s) Requested

Please check at least one. Fax Report Back

Cardiological

Neurological

Psychiatric, MD

Chiropractic

Orthopedic

Psychological, PHD

Dental

Rehabilitative Medicine(PMR)

ENT

Internal Medicine

Plastic Surgeon

Other:

Information Required in Report:

Need for treatment and duration

Need for surgery

Causal relationship to accident

Disability Rating

Can claimant work/daily activities

Permanency evaluation

Pre-existing conditions

Schedule loss of use

Request Submitted By*:

Date:

Special Instructions: