Service Service (Required)IMEPeer Review3rd Party Bill ReviewOther Line of Business Line of Business (Required)Auto/PIPWorkers CompDisabilityGeneral LiabilityOther Referral Party Information Referring Source (Adjuster Name) Referring Company Address City State Zip Phone (required) Fax Email Bill To Information Same Information as Referral Party Information (Required)YesNo [group group-billing] Billing Contact Name (Required) Billing Referring Company Billing Address Billing City Billing State Billing Zip Billing Phone Billing Fax Billing Email[/group] Claimant Information Name (Required) Claim Number (Required) Address City State Zip Claimant Phone (Required) Claimant Email (Required) Date of Injury / Accident (Required) Date of Birth (Required) Injury Description Service Details Specialty (Required) Body Parts Exam Due Date (Required) Report Due Date (Required) Re-examination (Required)YesNo [group original-examiner]Original Examiner[/group] Special Instructions Treating Physicians Physician Name (Required) Specialty (Required)—Please choose an option—AllergyAnesthesiologyChiropracticCritical Care/TraumaDentistryEar, Nose, ThroatEndocrinologyFamily PracticeGastro IntestinalGeneral SurgeryHematologyInternal MedicineNeurologyNeuropsychologyNeurosurgeryOccupational MedicineOccupational TherapyOral SurgeryOrthopedic SurgeryOtherPain ManagementPhysiatryPhysical TherapyPlastic SurgeryPsychiatryPsychologyVascular Surgery Additional Treating Provider? (Required)YesNo [group group-additional-treating-physicians] Physician Name (Required) Specialty (Required)—Please choose an option—AllergyAnesthesiologyChiropracticCritical Care/TraumaDentistryEar, Nose, ThroatEndocrinologyFamily PracticeGastro IntestinalGeneral SurgeryHematologyInternal MedicineNeurologyNeuropsychologyNeurosurgeryOccupational MedicineOccupational TherapyOral SurgeryOrthopedic SurgeryOtherPain ManagementPhysiatryPhysical TherapyPlastic SurgeryPsychiatryPsychologyVascular Surgery Address City State Zip Phone Fax Email [/group] Claimant Attorney Information Is the claimant represented? (Required)YesNo [group group-claimant-represented] Attorney Name Firm Name Address City State Zip Phone Fax [/group] Defense Attorney Information Is the defense attorney assigned? (Required)YesNo [group defense-attorney-assigned] Attorney Name Firm Name Address City State Zip Phone Fax Email [/group] Issues to be Addressed Issues to be AddressedSeparate cover letter to followHistory of injury and subsequent treatmentPresent statusComprehensive physical exam including non-physiologic findingsWhether objective findings support the subjective complaintsDiagnosis / PrognosisCan claimant return to work at this time with no restrictions?Other [group other-issues]Other[/group] Notification of Appointment Notification of AppointmentSend Appointment Letter to ClaimantCopy to Claimant's AttorneyCopy to Defense AttorneyCopy to Referring PartyCopy to Billing Party Medical Records Add Medical Records Here Alternative Delivery Method (Required)MailEmailFaxMedlogix PickupOther [group group-other-delivery-method]Other Delivery Method[/group]
