Medical Records ReviewReferral Party InformationReferring Source (Adjuster Name)Referring CompanyAddressAddress Line 1CityStateZip CodePhoneFaxEmailBill To InformationContact NameReferring CompanyAddressAddress Line 1CityStateZip CodePhoneFaxEmailPatient InformationNameAddressAddress Line 1CityStateZip CodeHome PhoneWork PhoneCell PhoneSocial SecurityDate of BirthEmployerOccupationClaim NumberDate of Injury / AccidentInjury DescriptionOther ComplaintsCurrently Working? Yes NoClaim Accepted? Yes NoJurisdiction StateType of Claim- Select -AutomobileGeneral LiabilityShort Term DisabilityLong Term DisabilityWorker's CompensationOtherPatient Attorney InformationIs the patient represented? Yes NoAttorney NameFirm NameAddressAddress Line 1CityStateZip CodePhoneFaxDefense Attorney InformationIs the defense attorney assigned? Yes NoAttorney NameFirm NameAddressAddress Line 1CityStateZip CodePhoneIssues to be Addressed Separate cover letter to follow History of injury and subsequent treatment Prior injuries and/or pre-existing conditions 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? OtherAppointment InformationSpecialty- Select -AllergyAnesthesiologyChiropracticCritical Care/TraumaDentistryEar, Nose, ThroatEndocrinologyFamily PracticeGastro IntestinalGeneral SurgeryHematologyInternal MedicineNeurologyNeuropsychologyNeurosurgeryOccupational MedicineOccupational TherapyOral SurgeryOrthopedic SurgeryOtherPain ManagementPhysiatryPhysical TherapyPlastic SurgeryPsychiatryItem 3PsychologyVascular SurgerySpecialty (Other)Requested Examiner's Name (Optional)Time Frame for AppointmentTime Frame for ReportTreating PhysiciansProvider Under Review (Name)AddressAddress Line 1CityStateZip CodePhoneFaxEmailSecondary ProviderAddressAddress Line 1CityStateZip CodePhoneFaxEmailSecondary ProviderAddressAddress Line 1CityStateZip CodePhoneFaxEmailSecondary ProviderAddressAddress Line 1CityStateZip CodePhoneFaxEmailMedical RecordsAre the records available? Yes NoDelivery Method- Select -MailEmailFaxCSG PickupOtherOther Delivery MethodSubmit Form
