| 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 |
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| CLAIMANT'S ATTORNEY | |||
| Claimant's Attorney: | Attorney Tele: | ||
| Law Firm: | Attorney Fax: |
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| Law Firm Address: | Send Appointment Letter to Claimant's Attorney: | Yes No N/A | |
| CLAIM INFORMATION | |||
| INSURED: | CLAIM No.: |
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| 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: |
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| Specialty Requested: | ADDITIONAL REQUESTS: |
TRANSPORTATION INTERPRETER INVOICE l BILL REVIEW Other: |
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| MEDICAL RECORDS: |
MAILED TO CME PLEASE OBTAIN SECURE UPLOAD BELOW SECURE EMAIL EXCHANGE |
ADDITIONAL INSTRUCTIONS: |
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Secure Document Upload
(Click submit button once when all applicable fields are complete.) | |||
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SECURE FORM EXCHANGE |
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