Independent Medical Exam (IME)

Referral Party Information

* Required for confirmation receipt

Bill To Information

Same as above

Patient Information

YesNo
YesNo

Patient Attorney Information

YesNo

Defense Attorney Information

YesNo

Issues to be Addressed

Separate cover letter to followHistory of injury and subsequent treatmentPrior injuries and/or pre-existing conditionsPresent statusComprehensive physical exam including non-physiologic findingsWhether objective findings support the subjective complaintsDiagnosis / PrognosisCan claimant return to work at this time with no restrictions?What are claimant's physical capabilities?Is claimant at Maximum Medical Improvement?Is there any permanency of injuries or residuals?Is current treatment reasonable and necessary?Is further treatment needed? If so, what kind, for what length of time and at what frequency?Other

Treating Physicians

Medical Records

YesNo

Notification of Appointment

Send Appointment Letter to PatientCopy to Claimant's AttorneyCopy to Defense AttorneyCopy to Referring PartyCopy to Billing Party

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