IME Request Form                  logoihc.bmp (60534 bytes)


Please complete this form to schedule an Independent Medical Examination (IME).

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:

Specific questions to be addressed by the IME doctor:



Copyright International Healthcare Consultants, Inc. 2000
Last revised: July 08, 2010