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   IME Referral Information

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   Claimant

  • Yes No
  • ...Medical Files

    Please upload files for the request packet.

    • Orthopedic
    • Chiropractic
    • Psychiatric
    • Internal Medicine
    • Physical Medicine(PM&R)
    • Neurologic
    • Neurosurgical
    • Dental / TMJ
    • Oral Surgery
    • Plastic Surgery
    • Diagnosis
    • Causal Relationship
    • Degree of Disability
    • Treatment Recommendations
    • Need for Surgery
    • Prognosis
    • Permanency
    • Apportionment
    • Variance from WCB
    • Schedule loss of use
    • Specific job capabilities / restrictions
    • MMI
    • Rocket Docket Case
    • 2012 Guidelines
    • 1996 Guidelines
    • C-4 Auth
  • Attorney Address

  • Treating Physician Address

  • Should be Empty:
After submitting you will be able to print your referral.

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