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Below is the information you submitted. If any of the information is incorrect, or if you have any questions regarding your request please contact us immediately. We suggest that you print a copy of this page for your records. Thank you.

Type of IME Requested: Type_of_IME

Date Requested: Date_Requested

Is this a re-exam? Re-exam?

Type of service selected: Type_of_Service

Contact Information:
Name: Contact_FullName
Title: Contact_Title
Organization: Contact_Organization
Work Phone Number: Contact_WorkPhone
Fax Number: Contact_FAX
Email Address: Contact_Email

Claimant Information:
Name: Claimant_Name
Social Security Number: Social_Security_Number
Date of Birth: Date_of_Birth
Address: Address
Telephone Number: Telephone_Number
Claim Number: Claim_Number
D/A: DA
Employer: Employer
Work Phone Number: Work_Phone_Number
WCB: WCB

Specialities Requested
(Specialties with a 'YES' next to them are requested specialties)
Orthopedic? Specialties_Requested_Orthopedic
Chiropractic? Specialties_Requested_Chiropractic
Psychiatric? Specialties_Requested_Psychiatric
Internal Medicine? Specialties_Requested_Internal_Medicine
Physical Medicine (PM&R)? Specialties_Requested_Physical_Medicine(PM&R)
Neurologic? Specialties_Requested_Neurologic
Neurosurgical? Specialties_Requested_Neurosurgical
Dental / TMJ? Specialties_Requested_Dental_TMJ
Oral Surgery? Specialties_Requested_Oral_Surgery
Plastic Surgery? Specialties_Requested_Plastic_Surgery
Additional Specialties? Additional_specialties

Location requested: Location_requested
Additional location information:Additional_location_information

Comment on:
Diagnosis? CommentOn_Diagnosis
Causal Relationship? CommentOn_Causal_Relationship
Degree of Disability? CommentOn_Degree_of_Disability
Treatment Recommendations / Necessity? CommentOn_Treatment_Recommendations_Necessity
Need for Surgery? CommentOn_Need_for_Surgery
Prognosis? CommentOn_Prognosis
Permanency? CommentOn_Permanency
Apportionment? CommentOn_Apportionment
Comment on Variance from WCB Guidelines? CommentOn_Variance_From_WCB_Guidelines
Schedule loss of use? CommentOn_Schedule_loss_of_use
Specific Job Capabilities / Restrictions? CommentOn_Specific_Job_Capabilities_Restrictions
MMI? CommentOn_MMI

Special Requests: Special_Requests

Copy appointment letter to: Copy_appointment_letter_to

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