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Expert Exams Admin
2021-03-16T22:33:27+00:00
Quick Referral for:
*
*Referrals received after 4:00 p.m. Eastern time, will be processed the next business day
IME
Record Organization & Indexing
Peer Review
Diagnostic Film Review
Medical Bill Review
Medical Bill Review - Summary Only
MSA Services
Med-Legal Nurse Review
Medical Cost Projections
Other
Other Quick Referral
Type of Case:
*
Liability
Auto
Workers Compensation
Occupational Accident
Other
Other Insurance Line of Business
Referral Date
MM slash DD slash YYYY
Date of Injury:
*
MM slash DD slash YYYY
Re Exam? Date of Last Exam?
MM slash DD slash YYYY
Claimant Information
Claimant Contact:
*
First
Last
DOB:
*
MM slash DD slash YYYY
Claimant Address:
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Claimant Phone:
Client Information
Client Contact:
*
First
Last
Client Phone:
*
Client Company:
Client Insured:
Client Email Address:
Client Claim Number:
*
Client Address:
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Billing
Bill to:
*
Client
Carrier/TPA
Billing Address:
*
Same as previous
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Carrier /TPA Name:
*
Carrier/ TPA Claim Number:
*
Carrier/TPA Email:
*
Carrier/TPA Phone:
*
Instructions
Rush Exam? Needed By?
Interpreter Needed?
Yes
No
Language
Transportation Needed?
Yes
No
Venue:
Choose Provider Specialty for IME/Peer Review
Orthopedic Surgery
Neurology
Neurosurgery
General Surgery
Ophthalmology
Physical Medicine & Rehab
Hand Surgery
Plastic Reconstructive Surgery
Infectious Disease
Psychiatry
Dentist
Oral Surgery
Chiropractor
Acupuncturist
PT/OT
Vocational Rehab Specialist
Radiology
Other
Other Specialty
Specialty Provider Instructions/ Additional questions for Examiner
Diagnosis
Prognosis
Current level of disability
Estimated length of disability
History of injury and medical treatment
MMI Status
Past medical history, including co-morbidities
Work Capabilities
Casual Relationship
Estimated RTW
Current treatment reasonable & necessary
Permanency Rating
Recommendation for further treatment
Evaluation of scarring
Additional questions to be addressed(list)
Specialty Provider Instructions/ Additional questions for Examiner
Terms and Conditions
*
I agree to the terms and conditions
Read Terms and Conditions here
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