ONLINE REFERRAL Independent Medical ExamService IME Perm Eval Peer Review 3rd Party Bill Review OtherLine of Business Auto/PIP Workers Comp Disability General Liability OtherReferral Party InformationReferring CompanyReferring Source (Adjuster Name)AddressCityStateZip CodePhoneFaxEmailBill to InformationSame Information as Referral Party Information Yes NoBilling Contact NameBilling Referring CompanyBilling AddressAddressCityStateZip CodeBilling PhoneBilling FaxBilling EmailClaimant InformationNameClaim NumberDate of BirthDate of LossAddressCityStateZip CodeClaimant PhoneClaimant EmailInjury DescriptionService DetailsSpecialtyBody PartsReport Due DateExam Due DateRe-examination Yes NoOriginal ExaminerSpecial InstructionsTreating PhysiciansPhysician NameSpecialtyAdditional Treating Provider? Yes NoPhysician NameSpecialtyPlaintiff Attorney InformationIs the claimant represented? Yes NoAttorney NameFirm NameAddressCityStateZip CodePhoneFaxEmailDefense Attorney InformationIs the defense attorney assigned? Yes NoAttorney NameFirm NameAddressCityStateZip CodeFaxPhoneEmailIssues to be AddressedIssues to be Addressed Separate cover letter to follow History of injury and subsequent treatment Prior injuries and/or pre-existing conditions Present status Comprehensive physical exam including non-physiologic findings Whether objective findings support the subjective complaints Diagnosis / Prognosis Can claimant return to work at this time with no restrictions? OtherOtherNotification of AppointmentNotification of Appointment Send Appointment Letter to Claimant Copy to Claimant's Attorney Copy to Defense Attorney Copy to Referring Party Copy to Billing PartyMedical RecordsAdd Medical Records HereChoose File Alternative Delivery Method- Select -MailEmailFaxMedlogix PickupOtherSubmit Form
