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Expert Exams Admin
2021-03-16T22:33:27+00:00
Referral for:
*
*Referrals received after 4:00 p.m. Eastern time, will be processed the next business day
Independent Medical Exam (IME)
Med-Legal Nurse Review
Liability Medical Bill Review
Qualified Medical Evaluator (QME)
Agreed Medical Evaluator (AME)
Peer Review
Record Organization & Indexing
Diagnostic Film Review
Medical Bill Review (Summary Only)
Medicare Set Aside (MSA) Services
Medical Cost Projections
Other
Other Quick Referral
Type of Case:
*
Liability
Auto
Personal Injury
Workers' Compensation
Occupational Accident
Insurance
Long-Term Disability
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?
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No
Language
Transportation Needed?
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Venue:
Choose Provider Specialty for IME/Peer Review
Acupuncturist
Allergy and Immunology
Anesthesiology
Audiologist
Cardiology
Cardiothoracic Surgery
Chiropractic
Dentistry
Dermatology
Forensic Psychology
Gastroenterology
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Physiatry (Physical Medicine & Rehab)
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Vocational Rehab Specialist
Other
Other Specialty
Specialty Provider Instructions
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 Tsdareatment
Evaluation of Scarring
Other (provide below)
Specialty Provider Instructions/ Additional Questions for Examiner
Terms and Conditions
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