Medical Records Review

    Referral Party Information

    * Required for confirmation receipt

    Bill To Information

    Same as above

    Patient Information


    Patient Attorney Information


    Defense Attorney Information


    Issues to be Addressed

    Separate cover letter to followHistory of injury and subsequent treatmentPrior injuries and/or pre-existing conditionsPresent statusComprehensive physical exam including non-physiologic findingsWhether objective findings support the subjective complaintsDiagnosis / PrognosisCan 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?Other

    Appointment Information

    Treating Physicians

    Medical Records