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Service Request
SERVICES
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CONTACT US
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SERVICES
ABOUT US
OUR TEAM
CONTACT US
Service Request
Date Of Request
*
Month/Day/Year
Claim Type
*
No Fault
Liability
Workers Comp
Other__
Other
Exam Type:
Clinic
Private Office
Exclusive (EME)
Claim#
*
Service Type
*
IME
Peer Review
Film Review
Other__
Intra-Op Photo Review
Other
Policy#
Reference #1
Date of Service
Month/Day/Year
Bill Amount
Provider
Reference #2
Date of Service
Month/Day/Year
Bill Amount
Provider
Reference #3
Date of Service
Month/Day/Year
Bill Amount
Provider
Re Evaluation
Yes
No
Insured
WCB #
Venue / County
State Jurisdiction
*
Requestor
*
Company
Adjuster Name
*
Telephone
Email
*
Fax
Address
City
State
Zip
Claimant
*
Date Of Birth
Month
Day
Year
Gender
Male
Female
Address
Telephone
City
State
Zip
Attorney
Telephone
Address
City
State
Zip
Treating Physician
Telephone
Address
City
State
Zip
Specialty
Ortho
Chiro
Neuro
Acu
PMR
Psych(MD)
Psych(PHD)
Other__
Other
Specialist Requested
Claimant's Injury
Date of Injury
*
Month
Day
Year
Issues to be Addressed
Causal Relationship
Need for Durable Medical Equipment
Need for Household Help
Prognosis
Target Return to Work Date
Frequency and Duration of Treatment
Degree of Disability
Schedule Loss of Use
Apportionment
Need for Diagnostic Testing
Occupational Status
Return to Work
Permanency
Other
Other
Additional Instructions
Medical Report Need By:
MM slash DD slash YYYY
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