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INDEPENDENT MEDICAL EXAM

NO FAULT  

Claimant(First MI Last)*:    Phone:
Street Address*:  
City*:     State*:      Zip:
Date of Injury*:   Claim # *:  
Policy Holder:     Date Report:
Policy #:      Date Feature Open:
 
Claimant's Attorney: Phone: 
Firm:     Street Address:
City:   State:   Zip:
 
Referring Agency  *:    Insurance Co *.   
Street Address:  Phone:
City: State:  Zip:
Claims Examiner Name*:   C/E Phone*
 
Type(s) of Exam(s) Requested

   Please check at least one.             

Cardiological Neurological Psychiatric, MD
Chiropractic Orthopedic Psychological, PHD
Dental Rehabilitative Medicine(PMR) ENT
Internal Medicine Plastic Surgeon Other:
Accupuncture
 
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
Request Submitted By*:  Date:
Special Instructions:

 

       

                                           

 



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