ONLINE REFERRALService IME Peer Review 3rd Party Bill Review OtherLine of Business Auto/PIP Workers Comp Disability General Liability OtherReferral Party InformationReferring Source (Adjuster Name)(Required)Referring CompanyAddressCityStateZipPhone(Required)FaxEmail Bill To InformationSame Information as Referral Party Information Yes NoContact NameReferring CompanyAddressCityStateZipPhoneFaxEmail Claimant InformationNameClaim NumberAddressCityStateZipPhoneEmail Date of Injury / Accident MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY Injury DescriptionService DetailsSpecialtyBody PartsExam Due Date MM slash DD slash YYYY Report Due Date MM slash DD slash YYYY Re-examination Yes NoSpecial InstructionsIssues to be Addressed Separate cover letter to follow History of injury and subsequent treatment Present status Comprehensive physical exam including non-physiologic findings Whether objective findings support the subjective complaints Diagnosis / Prognosis Can claimant return to work at this time with no restrictions? What are claimant's physical capabilities? Is claimant at Maximum Medical Improvement? Is there any permanency of injuries or residuals? Is current treatment reasonable and necessary? Is further treatment needed? If so, what kind, for what length of time and at what frequency? OtherTreating PhysiciansPhysician NameSpecialtyAllergyAnesthesiologyChiropracticCritical Care/TraumaDentistryEar, Nose, ThroatEndocrinologyFamily PracticeGastro IntestinalGeneral SurgeryHematologyInternal MedicineNeurologyNeuropsychologyNeurosurgeryOccupational MedicineOccupational TherapyOral SurgeryOrthopedic SurgeryOtherPain ManagementPhysiatryPhysical TherapyPlastic SurgeryPsychiatryPsychologyVascular SurgerySpecialty (Other)Additional Treating Provider? Yes NoPhysician NameSpecialtyAllergyAnesthesiologyChiropracticCritical Care/TraumaDentistryEar, Nose, ThroatEndocrinologyFamily PracticeGastro IntestinalGeneral SurgeryHematologyInternal MedicineNeurologyNeuropsychologyNeurosurgeryOccupational MedicineOccupational TherapyOral SurgeryOrthopedic SurgeryOtherPain ManagementPhysiatryPhysical TherapyPlastic SurgeryPsychiatryPsychologyVascular SurgerySpecialty (Other)AddressCityStateZipPhoneFaxEmailClaimant Attorney InformationIs the claimant represented? Yes NoAttorney NameFirm NameAddressCityStateZipPhoneFaxDefense Attorney InformationIs the defense attorney assigned? Yes NoAttorney NameFirm NameAddressCityStateZipPhoneFaxEmail Employer Yes NoEmployerAddressCityStateZipFaxEmailContact NameMedical RecordsAdd Medical Records HereMax. file size: 100 MB.Alternate Delivery MethodMailEmailFaxMedlogix PickupOtherOther Delivery MethodNotification of Appointment Send Appointment Letter to Claimant Copy to Claimant's Attorney Copy to Defense Attorney Copy to Referring Party Copy to Billing Party
