Medical Expense Management Inc.
Independent Medical Evaluation Request Form

*Note: All fields are required
Requestor Information
Requestor Name:
Email Address:

Adjuster Information
Date of request: / / Claim #: Re-Examination:
Company Name:
Adjuster Name: Telephone: Fax:
Email Address:
Address:
Insured: Address:
WCB#:

Claimant Information
Claimant Name: Telephone:
Address:
Occupation: Date of injury: / /
Nature of injury:
Social Security #: / / Date of birth: / /
Attorney: YesNo

Treating Physician
Treating Physician: Telephone:
Address:

Attorney Information
Attorney: Telephone:
Address:

Type of Examination
File review onlyOrthopedicChiropracticNeurologistPM&R
Other

Diagnosis/PrognosisDegree of disibilityHistory of injury & treatmentMG-2
Causal relationshipFurther treatment?ApportionmentPharmacy Review
PermanencySLUMMI?Functional Capacity Evaluation
Return to work?Light Duty?M&S (15-8)IMPAIRMENT RATING

Comments:

Type of Claim
GLNFWCBIOther Jurisdiction:

Copy report to: AttorneyAttending MDOther