IME 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.

    Can this claimant return to work in a full duty capacity?

    If not full duty, is light duty appropriate?  If so, give detailed restrictions and duration.

    Are present symptoms causally related to the accident?

    Are the symptoms related to a pre-existing condition or activities unrelated to the accident?

    Is the current medical treatment connected to the accident?

    Is the current medical treatment consistent with the severity of the accident? 

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

    Is the existing treatment plan medically necessary and appropriate?

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

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

    According to AMA guidelines, please provide a disability rating.  Address apportionment, if any.

                        Area of body:              Previous PPD rating?    Yes    No
    Other: