Medical Evaluations & Diagnostics
Peer Review Requisition
109 Carpenter Drive, #200   •   Sterling, VA 20164 •   (703) 478-7240 or 1-800-809-5687  •    FAX (703) 478-7255

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:     
Claim Number: Date of Injury:

Treating Physician

Name: Phone #: Fax #:


Attorney Information

Name: Phone #: Fax #:

 

Evaluation Services

Full Peer Review    Limited Peer Addendum   Rebuttal        Radiology Overread
Medical Specialty Requested:
Physician Requested:
Type Injury:
Jurisdiction:      
This file is for: Workman's Comp Auto Liability Other
Medical Records:  Fax In     Mail In     Other 

 

Issues that are to be addressed in the medical report:

   Provide diagnosis and a history.

    Are there pre-existing conditions that affected the course or duration of treatment, if yes please explain.

   Are the symptoms/complaints in questiona causally related to an injury sustained in the above accident?

    Is the existing treatment plan medically necessary and appropriate?

   Was the treatment rendered causally related to the injuries sustained in the accident?  If not, what specific treatment dates do not appear related or necessary as a result of the above accident?

    Does the patient require any future treatment?  If yes, please identify the treatment that can be anticipated.

    Based on the diagnosis, when would the patient be expected to reach maximum medical improvement?
    Other: