MEDICAL RECORDS REVIEW Referral Party InformationReferring Source (Adjuster Name)(Required) Referring Company(Required) Address(Required) City(Required) State(Required) Zip(Required) Phone(Required) Fax Email(Required) Bill To InformationContact Name(Required) Referring Company(Required) Address(Required) City(Required) State(Required) Zip(Required) Phone(Required) Fax Email(Required) Patient InformationName(Required) Address(Required) City(Required) State(Required) Zip(Required) Home Phone Work Phone Cell Phone Social Security Date of Birth MM slash DD slash YYYY Employer Occupation Claim Number(Required) Date of Injury / Accident(Required) MM slash DD slash YYYY Injury DescriptionOther ComplaintsCurrently Working?(Required) Yes No Claim Accepted?(Required) Yes No Jurisdiction State Type of ClaimAutomobileGeneral LiabilityShort Term DisabilityLong Term DisabilityWorker's CompensationOtherPatient Attorney InformationIs the patient represented? Yes No Attorney Name Firm Name Address City State Zip Phone Fax Defense Attorney InformationIs the defense attorney assigned? Yes No Attorney Name Firm Name Address City State Zip Phone Issues 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? 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 Appointment InformationSpecialtyAllergyAnesthesiologyChiropracticCritical Care/TraumaDentistryEar, Nose, ThroatEndocrinologyFamily PracticeGastro IntestinalGeneral SurgeryHematologyInternal MedicineNeurologyNeuropsychologyNeurosurgeryOccupational MedicineOccupational TherapyOral SurgeryOrthopedic SurgeryOtherPain ManagementPhysiatryPhysical TherapyPlastic SurgeryPsychiatryPsychologyVascular SurgerySpecialty (Other) Requested Examiner's Name (Optional) Time Frame for Appointment Time Frame for Report Treating PhysiciansProvider Under Review (Name)(Required) Address City(Required) State(Required) Zip(Required) Phone Fax Email Secondary Provider Address City State Zip Phone Fax Email Secondary Provider Address City State Zip Phone Fax Email Secondary Provider Address City State Zip Phone Fax Email Medical RecordsAre the records available? Yes No Delivery MethodMailEmailFaxCSG PickupOtherOther Delivery Method