IME Request Form                 

Please provide the following Requestor information:

First name
Last name
Title
Carrier/Client
Address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
FAX
E-mail

Please provide the following Claimant information:

First name
Last name
Address
Address/(cont.)
City
State/Province
Zip/Postal code
Country
Phone
SS number
Date of birth
Sex	Male Female
Claim number

Should we notify:

Claimant  Attorney  

Please provide the Attorney contact information:

First name
Last name
Firm Name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Work Phone
FAX

Treating Doctor

Name
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
FAX

Geograhic area for IME request (i.e. restrictions on location of IME Doctor)

City County  State   

IME SPECIALTY REQUESTD:

Chiropractic Orthopedic Cardiology Family Medicine Neurology Neurosurgery Osteopathy Psychiatry Psychology TMJ Dental Other

Specific questions to be addressed by the IME doctor: