Carrier Information

Analyst Name: Company Name:
Analyst Email: Company Address:
Analyst Tele: Analyst Fax:

CLAIMANT INFORMATION
Claimant Name: Claimant Tele:
Claimant SS No.: Alt Tele:
Claimant Address: Claimant's D/O/B

CLAIMANT'S ATTORNEY
Claimant's Attorney: Attorney Tele:
Law Firm: Attorney Fax:
Law Firm Address: Send Appointment Letter to Claimant's Attorney: Yes No N/A

CLAIM INFORMATION
INSURED: CLAIM No.:
DATE OF INJURY:    
Claim Type:
W/C
DIS
MP
BI
STD
G/L
Municipality
PIP
No Fault
LTD
Auto
Other
Type of Injury/Diagnosis:
State of Loss: Treating Physician:

REQUESTED SERVICE
Service Requested:
Medical Record Review
Peer Review (AP Calls)
Prescription | Drug Utilization Review
Independent Medical Evaluation
Personal Injury Protection IME
Personal Injury Protection Review
Neuropsych Evaluation
Functional Capacity Evaluation
Impairment Permanency Evaluation (IPE)
Re- Evaluation with Treatment Recommendation (RTR)
Additional Medical Record Review
Brief Medical Summary Review
Second Injury Fund
Medical Consultation
Medical Director Placement
Other 		Specific Issues to Address:
Describe Diagnosis
Secondary Diagnosis
Work Capacity Status
Restrictions and Limitations
Standard of Care
Necessity of Treatment
Is responding to treatment?
Prognosis
Is light duty available?
Pre-existing condition?
Impairment Rating
Functional Capacity
Physical Demands
Causal Relationship
Maximum Medical Improvement (MMI)
Return to work target date
Treatment Recommendation
Prescription Recommendation
Other:

Specialty Requested:

ADDITIONAL REQUESTS:
TRANSPORTATION
INTERPRETER
INVOICE l BILL REVIEW
Other:
MEDICAL RECORDS: MAILED
PLEASE OBTAIN
AUTHORIZATION
SECURE EMAIL

ADDITIONAL INSTRUCTIONS: