ONLINE REFERRAL Service(Required) IME Peer Review 3rd Party Bill Review Other Line of Business(Required) Auto/PIP Workers Comp Disability General Liability Other Referral Party InformationReferring Source (Adjuster Name)(Required) Referring Company Address City State Zip Phone(Required) Fax Email Bill To InformationSame Information as Referral Party Information(Required) Yes No Contact Name Referring Company Address City State Zip Phone Fax Email Claimant InformationName Claim Number Address City State Zip Phone Email Date of Injury / Accident MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY Injury DescriptionService DetailsSpecialty Body Parts Exam Due Date MM slash DD slash YYYY Report Due Date MM slash DD slash YYYY Re-examination Yes No Special Instructions Issues to be Addressed Separate cover letter to follow History of injury and subsequent treatment 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? 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 PhysiciansPhysician Name SpecialtyAllergyAnesthesiologyChiropracticCritical Care/TraumaDentistryEar, Nose, ThroatEndocrinologyFamily PracticeGastro IntestinalGeneral SurgeryHematologyInternal MedicineNeurologyNeuropsychologyNeurosurgeryOccupational MedicineOccupational TherapyOral SurgeryOrthopedic SurgeryOtherPain ManagementPhysiatryPhysical TherapyPlastic SurgeryPsychiatryPsychologyVascular SurgerySpecialty (Other) Additional Treating Provider?(Required) Yes No Physician Name SpecialtyAllergyAnesthesiologyChiropracticCritical Care/TraumaDentistryEar, Nose, ThroatEndocrinologyFamily PracticeGastro IntestinalGeneral SurgeryHematologyInternal MedicineNeurologyNeuropsychologyNeurosurgeryOccupational MedicineOccupational TherapyOral SurgeryOrthopedic SurgeryOtherPain ManagementPhysiatryPhysical TherapyPlastic SurgeryPsychiatryPsychologyVascular SurgerySpecialty (Other) Address City State Zip Phone Fax Email Claimant Attorney InformationIs the claimant represented?(Required) Yes No Attorney Name Firm Name Address City State Zip Phone Fax Defense Attorney InformationIs the defense attorney assigned?(Required) Yes No Attorney Name Firm Name Address City State Zip Phone Fax Email Employer(Required) Yes No Employer Address City State Zip Fax Email Contact Name Medical RecordsAdd Medical Records HereMax. file size: 100 MB.Alternate Delivery MethodMailEmailFaxMedlogix PickupOtherOther Delivery Method Notification of Appointment Send Appointment Letter to Claimant Copy to Claimant's Attorney Copy to Defense Attorney Copy to Referring Party Copy to Billing Party NameThis field is for validation purposes and should be left unchanged.