Independent Medical Exam (IME)

Referral Party Information

* Required for confirmation receipt

Bill To Information

Same as above

Patient Information


Patient Attorney Information


Defense Attorney Information


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


Notification of Appointment

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