Health Claim Resources

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 		IME Referral Form


IME Referral Form

Referror
Full Name: E-mail address:
Phone #:     Fax #:
Company: Hearing Date:
Address: City:      State:  

Zip:
Claimant Information
Name:
 
First Name
 MI Last Name
Social Security #: Date of Birth:  
Address: Home Phone:
Work Phone:  
City:      State:      Zip:  Fax:

Claimant Data
Insured:Name: Phone #: Fax #:
Claim Number: Date of Injury: Type: BI PIP
Injury: Job Description:
Claimant Attorney
Attroney: Phone #: Fax #:
Address: Law Firm:
City:      State:      Zip:   
Exam Type
Chiropractic  Dentistry  Dermatology Ear, Nose & Throat   General Surgery Internal Medicine/Cardiology
Neurology Opthalmology Oral Surgery Orthopedic Plastic Surgery Psychiatric
Rheumatology Urology FCE Other: 
Questions or Instructions to be Addressed:

   Casual Relationship

   History, Diagnosis, Prognosis

   Patient Reached Pre-injury Status?

   Length of Disability

   Work Capacity (Full Duty or Light Duty)

   Medical Treatment Recommendations

Other:

 

 

 

 

 

 

                             

 

©2006, Health Claim Resources
2222 Lake Avenue Suite 1A • Baltimore, MD 21213
phone: 410 366-4900 • fax: 410 366-4953