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
Upload Files
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First Party No-Fault and Automotive Liability
Workers Compensation
Federal, Longshoreman and Marine
Bodily Injury and Tort
Short Term Disability

Insurance Carriers
Employers
Law Firms
Third Party Administrators
Medical Review Partners
Investigative and Surveillance

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