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SCHEDULING AN INDEPENDENT MEDICAL EVALUATION ONLINE
Contact Information
Company:

Title:

Phone*:    Ext: 
First Name*:   Fax:
Last Name*:   Email:
Street*:   PO Box:
City*:   State*:  
Zip Code*:  

Bill To Company/Insurance Company
(Check to use Contact Information: )
Company:

Title:

Phone*:    Ext: 
First Name*:   Fax:
Last Name*:   Email:
Street*:   PO Box:
City*:   State*:  
Zip Code*:  
Notification Letter: Yes   No


Attorney
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Type of Attorney: Defense Attorney   Plaintiff Attorney   Individual  
Company:

Title:

Phone:  Ext: 
First Name: Fax:
Last Name Email:
Street: PO Box:
City: State:
Zip Code:
Trial Date:  
Notification Letter: Yes   No
Phone Consultation: Yes   No


Claimant Information
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First Name*:   Phone*:  
Last Name*:   Date of Birth*:    
Street*:   Injury Date*:    
PO Box:
City*:   SSN*:  
State*:   Claim Number*:  
Zip Code*:   Employer:
Treating Doctors: Chief Complaints*:  
Any requested forms that need to be filled out by the evaluator: Case history - Detailed Needed:
Notification Cite Letter: Yes   No


Other/3rd Party Information
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Company:

Title:

Phone:  Ext: 
First Name: Fax:
Last Name Email:
Street: PO Box:
City: State:
Zip Code:
Notification Cite Letter: Yes   No


Important Additional Information
Due Date:   Dr Specialty Needed:
Type of Claim*:  
Type of Services*: Hold down the CTRL key in order to choose more than one.
 
Claim State*:  
Medical Records - Number of Inches*  
Maximum Travel Distance*  
Litigated: Yes   No
Authorization for diagnostic testing: Yes   No Call
Verbal: Yes   No
AMA Guidelines 3rd   4th  5th  6th  None
Comments:

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