PLEASE HIGHLIGHT THE TYPE OF IME YOU ARE REQUESTING:

    Workers' Compensation No Fault / Liability Other

PLEASE ENTER THE DATE REQUESTED (MM/DD/YY):

IS THIS A RE-EXAM?

YES NO

TYPE OF SERVICE:

EXAM
REVIEW OF RECORDS
PEER REVIEW

PLEASE PROVIDE YOUR CONTACT INFORMATION:

Name
Title
Organization
Work Phone
FAX
E-mail

PLEASE ENTER CLAIMANT INFORMATION BELOW:

Claimant Name:    

Social Security Number:

Date of Birth:

Address (include city, state and zip code):

Telephone Number: 

Claim Number:

D/A:

Employer:

Work Phone Number:

WCB:

If necessary, fill out these additional fields:

Victim Name

DOC: (MM/DD/YY)

SPECIALTIES REQUESTED (CHECK ALL THAT APPLY):

ORTHOPEDIC                

CHIROPRACTIC

PSYCHIATRIC

INTERNAL MEDICINE      

PHYSICAL MEDICINE(PM&R)

NEUROLOGIC

NEUROSURGICAL

DENTAL / TMJ      

ORAL SURGERY

PLASTIC SURGERY           

IF YOU NEED ANY OTHER SPECIALTIES, INDICATE THEM BELOW:

LOCATION REQUESTED:

WESTCHESTER
ORANGE
DUTCHESS
ROCKLAND
ROCHESTER
ALBANY
SYRACUSE
BINGHAMTON
NEW YORK CITY (if you select this location, please follow the directions below)
LONG ISLAND (if you select this location, please follow the directions below)

IF YOU SELECTED:
NEW YORK CITY - ENTER THE BOROUGH NAME BELOW.
LONG ISLAND - ENTER THE REGION NAME BELOW.
OR
IF YOU NEED A LOCATION OTHER THAN THOSE LISTED, ENTER IT BELOW.

PLEASE COMMENT ON (CHECK ALL THAT APPLY):

DIAGNOSIS

CAUSAL RELATIONSHIP

DEGREE OF DISABILITY

TREATMENT RECOMMENDATIONS / NECESSITY

NEED FOR SURGERY

PROGNOSIS

PERMANENCY

APPORTIONMENT                         

15-8 MATERIALLY AND SUBSTANTIALLY

SCHEDULE LOSS OF USE

SPECIFIC JOB CAPABILITIES / RESTRICTIONS

MMI                                     

PLEASE ENTER ANY COMMENTS OR SPECIAL REQUESTS BELOW:

WE CAN COPY THE APPOINTMENT LETTER TO (you may also provide others):
    CLAIMANT'S ATTORNEY
    CLAIMANT'S ATTENDING PHYSICIAN
    WCB OFFICE

PLEASE INDICATE BELOW WHO YOU WOULD LIKE THE APPOINTMENT LETTER COPIED TO AND PLEASE INCLUDE THE COMPLETE ADDRESS.