Schedule an Independent Medical Examination

Injured Worker

Name:

Address:

Phone:

D.O.B.:

D.O.I.:

Claim #:

Body part and/or condition to be evaluated:

Specialty or Physician Requested:

Billing Information:

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.

$750 IME exams which includes examination, extensive review of records and a detailed report. There is also a late cancellation/no show fee of $500 for appointments cancelled less than 48 business hours. $750 for the first body part and $300 for each additional body part.

Questions To Be Addressed:
Issue of disability Prognosis Casual relationship History and diagnosis Malingering Treatment recommendations Permanent partial disability rating per AMA guidelines MMI Work status (light or full duty? work restrictions?)
Other Questions (please specify):


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: