Service Request

Services

IME Request
IME Re-Exam
PEER Request
MRI Re-Read
FCE - Functional Capacity Exam
Impairment Rating
Bill Review/Fee Schedule/UCR Review
Other: Please indicate service needed in the last field on the form in "additional info: section.

Indicate the service you need to request. All 2nd opinion exams are to considered an IME for purposes of this request form. A "Re-Exam" is if the doctor has already seen the examinee and a follow up is necessary. "Peer" if you need a review of records performed.

Attach a File

Insurance Company*

Examiner's Name (FN, LN)*

Examiner's Email address (required)*

This is required so we may send a confirmation to you

Examiner's mailing address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Claim #

WCB #

Jurisdiction of Claim (if not listed indicate in other area at end of form)

Policy #

Only required if you need this indicated on appointment letters and other contact information being sent on your behalf

Date of Loss / Incident

Insured

If the insured is the same person as the examinee you do not need to complete this area.

Claimant / Examinee information

Claimant's Name (FN,LN)

Date of Birth

Clmt's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Clmt's Home Phone

Clmt Cell Phone

Clmt Work Phone

If there is a known ext# , please indicate in other contact information below

Clmt Email address if avail

Other Contact Information

Injuries...

Treating Doctor & City

Specialty Requested Click all that apply

Chiro - D.C.
Medical Doctor - MD
Ortho
Neuro
PMR
Accu - AP/DOM/LaC
D.O. (indicate specialty below if appicable)
Other (indicate specialty below)

Indicate Specialty

Issues to Address: Click all that apply

Causal Relationship
Diagnosis
Prognosis
Further Treatment Info
Work Restrictions
Disability, if applicable
Discuss if addl. care is r/n/r

Add'l issues to address...

Upload your medical records here..

Drop files here or

Attorney info if applicable

Attorney Name (FN, LN), if no atty plz indicate.

Atty's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Atty Phone

Atty Fax

Atty Email address if avail

Add'l Atty Info...

Additional Information regarding request/clmt/injuries/topics, etc....

Claimant / Examinee information

Attorney info if applicable

QUICK LINKS

National Coverage with
Regional Service Centers

Service Request

Claimant / Examinee information

Attorney info if applicable

QUICK LINKS

Are You New To Certified Medical Consultants?

Let us know how we can help …

National Coverage with Regional Service Centers

Are You New To
Certified Medical Consultants?

National Coverage with
Regional Service Centers