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