Schedule a Disability/Permanent Impairment Rating

Injured Worker

Name:

Address:

Phone:

D.O.B.:

D.O.I.:

Claim #:

Body part and/or condition to be evaluated:

Specialty or Physician Requested:

Send Bill To:

Name:

Company:

Address:

Phone:

Fax:


Agreement

I agree to the fees and policies that I have checked and understand that this examination is not subject to any fee schedules. I accept financial responsibility for this exam.
By checking this box you are signifying that you agree to these terms.

EVALUATIONS

Prepayment and records must be received at least 7 days prior to appointment except for established patient. There will be additional fees for any x-rays taken if the patient does not bring their own.

Disability/Permanent Partial Impairment Rating. $250 Established Patient / $500 New Patient. (* This is not an Independent Medical Examination.) Please perform a single visit (extensive) evaluation. There is also a late cancellation/no show fee of $75 for appointments cancelled less than 48 business hours.

Fax Additional Copy of Report To:

Name:

Phone:

Fax:


Fax a copy of report to Claimant's Attorney?: Yes No
Name of Law Firm:

Name:

Phone:

Fax:

Fax a copy of report to Defense Attorney?: Yes No
Name of Law Firm:

Name:

Phone:

Fax:

Requestor Information:
Name:

Company Name:

Phone:

Fax:

Address:

Please leave the following field blank: