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Referral Form

This referral form provides information about a claimant seeking an independent medical examination (IME) or records review. It includes the claimant's name, address, date of birth, social security number, injury details, treating physician, and referring attorney information. The IME doctor is asked to address the claimant's diagnosis, prognosis, current disability level, causal relationship to the injury, treatment history and needs, prior injuries, pre-existing conditions, ability to return to work, physical capabilities, and any loss of function. The completed form should be faxed to IME Solutions for scheduling of the required examination or report.

Uploaded by

Derek Banas
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
219 views

Referral Form

This referral form provides information about a claimant seeking an independent medical examination (IME) or records review. It includes the claimant's name, address, date of birth, social security number, injury details, treating physician, and referring attorney information. The IME doctor is asked to address the claimant's diagnosis, prognosis, current disability level, causal relationship to the injury, treatment history and needs, prior injuries, pre-existing conditions, ability to return to work, physical capabilities, and any loss of function. The completed form should be faxed to IME Solutions for scheduling of the required examination or report.

Uploaded by

Derek Banas
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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Referral Form

Service Needed: IME Second Opinion Medical Appointment needed by:


Records Review FCE
Report needed by:
Claimant Name:
Address:
Address:
Phone:
Social Security #:
Date of Birth:

Date of Injury: Jurisdiction:


Injury to be evaluated:
Any other complaints:
Treating doctor:
Employer:
Occupation:

Referred by:
Email address:
Company:
Address:
Address:
Phone:Fax:

Bill To:
Claim #:
Address:
Address:
Phone:Fax:

Defense Attorney:
Company:
Address:
Address:
Phone:Fax:

Plaintiff Attorney:
Company:
Address:
Address:
Phone:Fax:

IME will address Diagnosis, Prognosis, Current Disability, Causal Relationship


History of the Injury, Medical Treatment, Prior Injuries,
Further treatment needed
and Pre-Existing Conditions.
Is treatment reasonable and necessary MMI
Can claimant return to work at this time?
What are claimant's physical capabilities?
Any loss of function or use?

Please fax the Referral Form to IME Solutions, Inc. @ (724) 219-3959

P.O. Box 511


Greensburg, PA 15601
Office (724) 219-3257
Fax (724) 219-3959

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