Independent Medical Evaluations

Claim Information
Claim/Control Number
Diagnosis
Date of Injury/Disability
Attorney Name
First Last
Attorney Phone
Attorney Address
Street Address Address Line 2 City State ZIP Code
Employer
Employer Phone
Attending/Treating Physician
Attending/Treating Physician Address
Street Address Address Line 2 City State ZIP Code
Phone

Primary Contact Information
Responsible Party
Contact Name
First Last
Contact Address
Street Address Address Line 2 City State ZIP Code
Contact Phone
Contact Company
Contact Title
Payor ID #
Contact Email*
Fax Number
Special Instructions / Requested Physician
Terms & Conditions*
- I agree to the terms & conditions
By checking this box you agree to the terms & pre-payment conditions listed below.
Name
This field is for validation purposes and should be left unchanged.

Exam Information