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

Max. file size: 128 MB.

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

Max. file size: 128 MB.

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

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National Coverage with Regional Service Centers

Are You New To
Certified Medical Consultants?

National Coverage with
Regional Service Centers