{"id":583,"date":"2018-03-28T13:10:56","date_gmt":"2018-03-28T13:10:29","guid":{"rendered":"https:\/\/medlogix.com\/forms\/independent-medical-exam-ime\/"},"modified":"2024-04-09T16:02:37","modified_gmt":"2024-04-09T20:02:37","slug":"independent-medical-exam-ime","status":"publish","type":"page","link":"https:\/\/medlogix.com\/independent-medical-exam-ime\/","title":{"rendered":"Independent Medical Exam (IME)"},"content":{"rendered":"\n<h1>\n\t\tONLINE REFERRAL\n\t<\/h1>\n\t<div class='fluentform ff-default fluentform_wrapper_24 ffs_default_wrap'><form data-form_id=\"24\" id=\"fluentform_24\" class=\"frm-fluent-form fluent_form_24 ff-el-form-top ff_form_instance_24_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_24_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Independent Medical Exam<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='583' \/><input type=\"hidden\" id=\"_fluentform_24_fluentformnonce\" name=\"_fluentform_24_fluentformnonce\" value=\"536813fa40\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/583\" \/><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-24_1\" ><h2>Service<\/h2><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\" \"> <\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_83f053d87bd17495abdf8fe58acfbc51><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"IME\"  id='input_radio_83f053d87bd17495abdf8fe58acfbc51' aria-label='IME' aria-invalid='false' aria-required=false> <span>IME<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_78cf058edd7343e3c746120a04ff20db><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Perm Eval\"  id='input_radio_78cf058edd7343e3c746120a04ff20db' aria-label='Perm Eval' aria-invalid='false' aria-required=false> <span>Perm Eval<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_2b495b0504e1b6082875a3b1b899cba9><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Peer Review\"  id='input_radio_2b495b0504e1b6082875a3b1b899cba9' aria-label='Peer Review' aria-invalid='false' aria-required=false> <span>Peer Review<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_f5f9de4fee49601ed424b3ef15e1eacc><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"3rd Party Bill Review\"  id='input_radio_f5f9de4fee49601ed424b3ef15e1eacc' aria-label='3rd Party Bill Review' aria-invalid='false' aria-required=false> <span>3rd Party Bill Review<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_7438c76f592045292e1d2b86e9ba1551><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Other\"  id='input_radio_7438c76f592045292e1d2b86e9ba1551' aria-label='Other' aria-invalid='false' aria-required=false> <span>Other<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-24_2\" ><h2>Line of Business<\/h2><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\" \"> <\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_11_e05d9687f0530fbf3e3f55009be08c46><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Auto\/PIP\"  id='input_radio_11_e05d9687f0530fbf3e3f55009be08c46' aria-label='Auto\/PIP' aria-invalid='false' aria-required=false> <span>Auto\/PIP<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_11_4f296512d85b176f7a21b3bb7db25523><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Workers Comp\"  id='input_radio_11_4f296512d85b176f7a21b3bb7db25523' aria-label='Workers Comp' aria-invalid='false' aria-required=false> <span>Workers Comp<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_11_07cb95d5e7ecd6f14d3389ce2c4aa167><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Disability\"  id='input_radio_11_07cb95d5e7ecd6f14d3389ce2c4aa167' aria-label='Disability' aria-invalid='false' aria-required=false> <span>Disability<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_11_1cb8127203d088e35fb777a45b04115e><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"General Liability\"  id='input_radio_11_1cb8127203d088e35fb777a45b04115e' aria-label='General Liability' aria-invalid='false' aria-required=false> <span>General Liability<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_11_dbe6b5689e5be47fc95b6b9393cc469b><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Other\"  id='input_radio_11_dbe6b5689e5be47fc95b6b9393cc469b' aria-label='Other' aria-invalid='false' aria-required=false> <span>Other<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-24_3\" ><h3 class='ff-el-section-title'>Referral Party Information<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_24_input_text' aria-label=\"Referring Company\">Referring Company<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_24_input_text\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_24_input_text_1' aria-label=\"Referring Source (Adjuster Name)\">Referring Source (Adjuster Name)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_24_input_text_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_1\" ><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_1_address_line_1_' aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_1]\" id=\"ff_24_address_1_address_line_1_\" class=\"ff-el-form-control\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_1_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_24_address_1_city_\" class=\"ff-el-form-control\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_1_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[state]\" id=\"ff_24_address_1_state_\" class=\"ff-el-form-control\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_1_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[zip]\" id=\"ff_24_address_1_zip_\" class=\"ff-el-form-control\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_24_phone' aria-label=\"Phone\">Phone<\/label><\/div><div class='ff-el-input--content'><input name=\"phone\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone\" id=\"ff_24_phone\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_input_text_2' aria-label=\"Fax\">Fax<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_24_input_text_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_email' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_24_email\" class=\"ff-el-form-control\" data-name=\"email\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-24_4\" ><h3 class='ff-el-section-title'>Bill to Information<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Same Information as Referral Party Information\">Same Information as Referral Party Information<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_2_73b999b0486177f34a60a15b82d6d56e><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_2_73b999b0486177f34a60a15b82d6d56e' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_2_e37953182d6dab6719324ab3bb36909d><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_2_e37953182d6dab6719324ab3bb36909d' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_2  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_24_input_text_3' aria-label=\"Billing Contact Name\">Billing Contact Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_3\" class=\"ff-el-form-control\" data-name=\"input_text_3\" id=\"ff_24_input_text_3\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_24_input_text_4' aria-label=\"Billing Referring Company\">Billing Referring Company<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" data-name=\"input_text_4\" id=\"ff_24_input_text_4\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address has-conditions\" data-type=\"address-element\" data-name=\"address_2\" ><div class='ff-el-input--label'><label aria-label=Billing Address>Billing Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_2_address_line_1_' aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_2[address_line_1]\" id=\"ff_24_address_2_address_line_1_\" class=\"ff-el-form-control\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_2_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_2[city]\" id=\"ff_24_address_2_city_\" class=\"ff-el-form-control\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_2_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_2[state]\" id=\"ff_24_address_2_state_\" class=\"ff-el-form-control\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_2_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_2[zip]\" id=\"ff_24_address_2_zip_\" class=\"ff-el-form-control\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_3  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_phone_1' aria-label=\"Billing Phone\">Billing Phone<\/label><\/div><div class='ff-el-input--content'><input name=\"phone_1\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone_1\" id=\"ff_24_phone_1\" inputmode=\"tel\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_phone_2' aria-label=\"Billing Fax\">Billing Fax<\/label><\/div><div class='ff-el-input--content'><input name=\"phone_2\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone_2\" id=\"ff_24_phone_2\" inputmode=\"tel\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_email_1' aria-label=\"Billing Email\">Billing Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email_1\" id=\"ff_24_email_1\" class=\"ff-el-form-control\" data-name=\"email_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-24_5\" ><h3 class='ff-el-section-title'>Claimant Information<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_24_input_text_5' aria-label=\"Name\">Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_5\" class=\"ff-el-form-control\" data-name=\"input_text_5\" id=\"ff_24_input_text_5\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_24_input_text_6' aria-label=\"Claim Number\">Claim Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_6\" class=\"ff-el-form-control\" data-name=\"input_text_6\" id=\"ff_24_input_text_6\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_24_datetime_2' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='m\/d\/Y' type=\"text\" name=\"datetime_2\" id=\"ff_24_datetime_2\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_2\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_24_datetime_3' aria-label=\"Date of Loss\">Date of Loss<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='m\/d\/Y' type=\"text\" name=\"datetime_3\" id=\"ff_24_datetime_3\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_3\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_3\" ><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_3_address_line_1_' aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_3[address_line_1]\" id=\"ff_24_address_3_address_line_1_\" class=\"ff-el-form-control\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_3_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_3[city]\" id=\"ff_24_address_3_city_\" class=\"ff-el-form-control\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_3_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_3[state]\" id=\"ff_24_address_3_state_\" class=\"ff-el-form-control\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_3_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_3[zip]\" id=\"ff_24_address_3_zip_\" class=\"ff-el-form-control\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_phone_3' aria-label=\"Claimant Phone\">Claimant Phone<\/label><\/div><div class='ff-el-input--content'><input name=\"phone_3\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone_3\" id=\"ff_24_phone_3\" inputmode=\"tel\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_email_2' aria-label=\"Claimant Email\">Claimant Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email_2\" id=\"ff_24_email_2\" class=\"ff-el-form-control\" data-name=\"email_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_description' aria-label=\"Injury Description\">Injury Description<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=false name=\"description\" id=\"ff_24_description\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description\" ><\/textarea><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-24_6\" ><h3 class='ff-el-section-title'>Service Details<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_24_input_text_7' aria-label=\"Specialty\">Specialty<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_7\" class=\"ff-el-form-control\" data-name=\"input_text_7\" id=\"ff_24_input_text_7\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_input_text_8' aria-label=\"Body Parts\">Body Parts<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_8\" class=\"ff-el-form-control\" data-name=\"input_text_8\" id=\"ff_24_input_text_8\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_datetime' aria-label=\"Report Due Date\">Report Due Date<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" id=\"ff_24_datetime\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_datetime_1' aria-label=\"Exam Due Date\">Exam Due Date<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_1\" id=\"ff_24_datetime_1\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_1\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Re-examination\">Re-examination<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_3_429f0e9ee5edb88b12e470897dc6dd11><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_3_429f0e9ee5edb88b12e470897dc6dd11' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_3_d4b49934fc73f3e22fac1aee91d71b41><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_3_d4b49934fc73f3e22fac1aee91d71b41' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_24_input_text_9' aria-label=\"Original Examiner\">Original Examiner<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_9\" class=\"ff-el-form-control\" data-name=\"input_text_9\" id=\"ff_24_input_text_9\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_description_1' aria-label=\"Special Instructions\">Special Instructions<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=false name=\"description_1\" id=\"ff_24_description_1\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_1\" ><\/textarea><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-24_7\" ><h3 class='ff-el-section-title'>Treating Physicians<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_input_text_10' aria-label=\"Physician Name\">Physician Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_10\" class=\"ff-el-form-control\" data-name=\"input_text_10\" id=\"ff_24_input_text_10\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_input_text_20' aria-label=\"Specialty\">Specialty<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_20\" class=\"ff-el-form-control\" data-name=\"input_text_20\" id=\"ff_24_input_text_20\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Additional Treating Provider?\">Additional Treating Provider?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_4_59cb6bb02ddd21dd4ed4b7fab7ee9220><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_4_59cb6bb02ddd21dd4ed4b7fab7ee9220' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_4_5ceaa7df79eef63e98ac26aba6188a94><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_4_5ceaa7df79eef63e98ac26aba6188a94' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_input_text_11' aria-label=\"Physician Name\">Physician Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_11\" class=\"ff-el-form-control\" data-name=\"input_text_11\" id=\"ff_24_input_text_11\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_input_text_21' aria-label=\"Specialty\">Specialty<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_21\" class=\"ff-el-form-control\" data-name=\"input_text_21\" id=\"ff_24_input_text_21\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-24_8\" ><h3 class='ff-el-section-title'>Plaintiff Attorney Information<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Is the claimant represented?\">Is the claimant represented?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_5_4fffdf3bbff36d9e6014607399189b1c><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_5_4fffdf3bbff36d9e6014607399189b1c' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_5_dc5943c0637e82f7723ba039b1219dcb><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_5_dc5943c0637e82f7723ba039b1219dcb' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_10\"  class='ff-t-container ff-column-container ff_columns_total_1  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_input_text_13' aria-label=\"Attorney Name\">Attorney Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_13\" class=\"ff-el-form-control\" data-name=\"input_text_13\" id=\"ff_24_input_text_13\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_input_text_14' aria-label=\"Firm Name\">Firm Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_14\" class=\"ff-el-form-control\" data-name=\"input_text_14\" id=\"ff_24_input_text_14\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_5\" ><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_5_address_line_1_' aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_5[address_line_1]\" id=\"ff_24_address_5_address_line_1_\" class=\"ff-el-form-control\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_5_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_5[city]\" id=\"ff_24_address_5_city_\" class=\"ff-el-form-control\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_5_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_5[state]\" id=\"ff_24_address_5_state_\" class=\"ff-el-form-control\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_5_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_5[zip]\" id=\"ff_24_address_5_zip_\" class=\"ff-el-form-control\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_11\"  class='ff-t-container ff-column-container ff_columns_total_3  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_phone_7' aria-label=\"Phone\">Phone<\/label><\/div><div class='ff-el-input--content'><input name=\"phone_7\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone_7\" id=\"ff_24_phone_7\" inputmode=\"tel\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_phone_8' aria-label=\"Fax\">Fax<\/label><\/div><div class='ff-el-input--content'><input name=\"phone_8\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone_8\" id=\"ff_24_phone_8\" inputmode=\"tel\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_email_4' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email_4\" id=\"ff_24_email_4\" class=\"ff-el-form-control\" data-name=\"email_4\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-24_9\" ><h3 class='ff-el-section-title'>Defense Attorney Information<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Is the defense attorney assigned?\">Is the defense attorney assigned?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_6_dcc7097967ac7081d36e420f20e2edaa><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_6_dcc7097967ac7081d36e420f20e2edaa' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_6_bf394427477b5a2f30e95a8940d16e6d><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_6_bf394427477b5a2f30e95a8940d16e6d' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_12\"  class='ff-t-container ff-column-container ff_columns_total_1  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_input_text_18' aria-label=\"Attorney Name\">Attorney Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_18\" class=\"ff-el-form-control\" data-name=\"input_text_18\" id=\"ff_24_input_text_18\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_input_text_19' aria-label=\"Firm Name\">Firm Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_19\" class=\"ff-el-form-control\" data-name=\"input_text_19\" id=\"ff_24_input_text_19\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_6\" ><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_6_address_line_1_' aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_6[address_line_1]\" id=\"ff_24_address_6_address_line_1_\" class=\"ff-el-form-control\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_6_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_6[city]\" id=\"ff_24_address_6_city_\" class=\"ff-el-form-control\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_6_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_6[state]\" id=\"ff_24_address_6_state_\" class=\"ff-el-form-control\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_address_6_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_6[zip]\" id=\"ff_24_address_6_zip_\" class=\"ff-el-form-control\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_13\"  class='ff-t-container ff-column-container ff_columns_total_3  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_phone_9' aria-label=\"Fax\">Fax<\/label><\/div><div class='ff-el-input--content'><input name=\"phone_9\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone_9\" id=\"ff_24_phone_9\" inputmode=\"tel\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_phone_10' aria-label=\"Phone\">Phone<\/label><\/div><div class='ff-el-input--content'><input name=\"phone_10\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone_10\" id=\"ff_24_phone_10\" inputmode=\"tel\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_email_5' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email_5\" id=\"ff_24_email_5\" class=\"ff-el-form-control\" data-name=\"email_5\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-24_10\" ><h3 class='ff-el-section-title'>Issues to be Addressed<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Issues to be Addressed\">Issues to be Addressed<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_b5a85b27d1ba970d4b4c26be0ab69f7c><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Separate cover letter to follow\"  id='checkbox_b5a85b27d1ba970d4b4c26be0ab69f7c' aria-label='Separate cover letter to follow' aria-invalid='false' aria-required=false> <span>Separate cover letter to follow<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_a917100f8aa89005e3b8fcb604b99449><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"History of injury and subsequent treatment\"  id='checkbox_a917100f8aa89005e3b8fcb604b99449' aria-label='History of injury and subsequent treatment' aria-invalid='false' aria-required=false> <span>History of injury and subsequent treatment<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_7306422b8b2aeb10c56d870adb03f8c9><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Prior injuries and\/or pre-existing conditions\"  id='checkbox_7306422b8b2aeb10c56d870adb03f8c9' aria-label='Prior injuries and\/or pre-existing conditions' aria-invalid='false' aria-required=false> <span>Prior injuries and\/or pre-existing conditions<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_b1577a0879ceb9f0f869a83fc987f5db><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Present status\"  id='checkbox_b1577a0879ceb9f0f869a83fc987f5db' aria-label='Present status' aria-invalid='false' aria-required=false> <span>Present status<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_f49488eb741257d2af1d9421893c0ffc><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Comprehensive physical exam including non-physiologic findings\"  id='checkbox_f49488eb741257d2af1d9421893c0ffc' aria-label='Comprehensive physical exam including non-physiologic findings' aria-invalid='false' aria-required=false> <span>Comprehensive physical exam including non-physiologic findings<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_be06d83c7b7eadd0f99f88bdb5fd5355><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Whether objective findings support the subjective complaints\"  id='checkbox_be06d83c7b7eadd0f99f88bdb5fd5355' aria-label='Whether objective findings support the subjective complaints' aria-invalid='false' aria-required=false> <span>Whether objective findings support the subjective complaints<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_d0c3382967c14e738a2861dfc4b00325><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Diagnosis \/ Prognosis\"  id='checkbox_d0c3382967c14e738a2861dfc4b00325' aria-label='Diagnosis \/ Prognosis' aria-invalid='false' aria-required=false> <span>Diagnosis \/ Prognosis<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_c40ab01110f0890e3bf4d192861da2e4><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Can claimant return to work at this time with no restrictions?\"  id='checkbox_c40ab01110f0890e3bf4d192861da2e4' aria-label='Can claimant return to work at this time with no restrictions?' aria-invalid='false' aria-required=false> <span>Can claimant return to work at this time with no restrictions?<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_9d52444ce78225b0da5358e535696eca><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Other\"  id='checkbox_9d52444ce78225b0da5358e535696eca' aria-label='Other' aria-invalid='false' aria-required=false> <span>Other<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_input_text_17' aria-label=\"Other\">Other<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_17\" class=\"ff-el-form-control\" data-name=\"input_text_17\" id=\"ff_24_input_text_17\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-24_11\" ><h3 class='ff-el-section-title'>Notification of Appointment<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Notification of Appointment\">Notification of Appointment<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_f6a473c21b7c1fdcf81205b99eaf1a8c><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Send Appointment Letter to Claimant\"  id='checkbox_1_f6a473c21b7c1fdcf81205b99eaf1a8c' aria-label='Send Appointment Letter to Claimant' aria-invalid='false' aria-required=false> <span>Send Appointment Letter to Claimant<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_ec5b354db557fde3dd0df33f504dc76a><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Copy to Claimant's Attorney\"  id='checkbox_1_ec5b354db557fde3dd0df33f504dc76a' aria-label='Copy to Claimant&#039;s Attorney' aria-invalid='false' aria-required=false> <span>Copy to Claimant's Attorney<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_f062e32bfa9f39c91aa20806f56b800d><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Copy to Defense Attorney\"  id='checkbox_1_f062e32bfa9f39c91aa20806f56b800d' aria-label='Copy to Defense Attorney' aria-invalid='false' aria-required=false> <span>Copy to Defense Attorney<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_3c5d1ea7463a8260eaa6bff956634674><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Copy to Referring Party\"  id='checkbox_1_3c5d1ea7463a8260eaa6bff956634674' aria-label='Copy to Referring Party' aria-invalid='false' aria-required=false> <span>Copy to Referring Party<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_191044de03dfe80a6103a9a0994501bd><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Copy to Billing Party\"  id='checkbox_1_191044de03dfe80a6103a9a0994501bd' aria-label='Copy to Billing Party' aria-invalid='false' aria-required=false> <span>Copy to Billing Party<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-24_12\" ><h3 class='ff-el-section-title'>Medical Records<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_file-upload_1' aria-label=\"Add Medical Records Here\">Add Medical Records Here<\/label><\/div><div class='ff-el-input--content'><label for='ff_24_file-upload_1' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn' tabindex='0'>Choose File<\/span> <input type=\"file\" name=\"file-upload\" id=\"ff_24_file-upload_1\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"file-upload\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_24_dropdown_2' aria-label=\"Alternative Delivery Method\">Alternative Delivery Method<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_2\" id=\"ff_24_dropdown_2\" class=\"ff-el-form-control\" data-name=\"dropdown_2\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Select -<\/option><option value=\"Mail\"  >Mail<\/option><option value=\"Email\"  >Email<\/option><option value=\"Fax\"  >Fax<\/option><option value=\"Medlogix Pickup\"  >Medlogix 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