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   The Independent Medical
   Evaluation Specialists Inc.


IME REQUEST FORM

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  PATIENT INFORMATION    
Name: Date of Loss:
Address: Claim #:
  Claim Type:
City: For W/C Only  
State: Claim Accepted?    Yes           No
Zip: Employer:
Phone: Address:
DOB:  
SS #: City:
Injury: State:
Tx Dr.: Zip:
       
  PATIENT ATTORNEY 

(if applicable)

  
Name: Address:
Firm:  
Phone: City:
Fax: State:
    Zip:
       
  REFERRAL INFORMATION    
Name: Address:
Co:  
Phone: City:
Fax: State:
E-Mail: Zip:
       
  BILLING INFORMATION

Check here if same as referral
Name: Address:
Co:  
Phone: City:
Fax: State:
E-mail: Zip:
       
  DEFENSE ATTORNEY

(if applicable)

  
Name: Address:
Firm:  
Phone: City:
Fax: State:
E-mail: Zip:
       
     
APPOINTMENT INFORMATION

Specialty or Physician Requested:

Location Requested:

Timeframe For Appointment:

Would you like us to:

Notify Patient/Patient Attorney?

       Yes     No

Copy Defense Attorney?

      Yes     No

Copy Billing Party?

       Yes     No

Arrange Transportation?

       Yes     No

Arrange An Interpreter?

       Yes     No


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