DME Referral
109 Carpenter Drive, #200   •   Sterling, VA 20164 • (703) 478-7240 or 1-800-809-5687  •    FAX (703) 478-7255
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Requested By

Your Name: E-mail address:
Phone #:     Fax #:
Company:    
Address:    

 
City:      State:    Zip:

Claimant Information

Name:
 
First Name
 MI Last Name
Soc. Sec. Number: Date of Birth:  
Address:    
     
  City:      State:      Zip:     
Home Phone: Work Phone:  
Claim Number: Date of Injury:

Treating Physician

Name: Phone #: Fax #:


Attorney Information

Name: Phone #: Fax #:


Hearing Information

Hearing Scheduled: Yes No Hearing Date: 


Evaluation Services

IME   Second Opinion  Consultation Addendum  Other
Medical Specialty Requested:
Physician Requested:
Type Injury:
Anatomical Region:
Jurisdiction:      
This file is for: Workman's Comp Auto Liability Other
NCM/Adjuster to write IME letter to doctor? Yes  No
RTW Preliminary report needed? Yes  No
IME appointment date by:
Medical Records:  Fax In     Mail In     Other 

 

Issues that are to be addressed in the IME report:

   Provide diagnosis, prognosis, and a history.

    Are the injuries in question causally related to a pre-existing condition?

  Are the injuries in question causally related to the accident?

    Is the existing treatment plan medically necessary and appropriate?

    Does the patient need future treatment?   If so, provide type of treatment and duration.

    Does the patient need surgery?  If so, provide type of surgery and length of recovery.

    Has the claimant reached maximum medical improvement?  If not, when is MMI expected?

    Other: