SERVICE REQUEST FORM
* Required fields

Referral Source: *
Company: *
Address:
City, State, Zip:
Phone: *
Email: *
Fax:
Claim Number: *

Coverage

Worker's Compensation/Jurisdiction:
General Liability
Auto/Jurisdiction:
Short /Long Term Disability
Medical Malpractice
Longshore
Other:

Services

Functional Capacity Evaluation
Forensic Accountant
Forensic Economist
Hospital Bill Audit
Independent Medical Evaluation
Job Analysis
Life Care Plan
Legal Nurse Review
Peer Review
Pro-Plus
Record/Film Review
Medical Cost Projection
Medical Onsite Case Management
Limited Assignment
Telephonic Case Management
Vocational Case Management
Vocational/Psychological Testing
Wage Loss Analysis
Claimant Name: *
Claimant Address:
Claimant City, State, Zip:
Claimant Telephone:
Claimant Social Security:
Claimant Date of Birth:
Occupation:
Date of Loss:
Treating Physician:
Injury/Disability:
Insured Contact:
Insured Address:
Insured City, State, Zip:
Insured Phone Number:
Claimant Attorney:
Claimant Attorney Address:
Claimant Attorney City, State, Zip:
Claimant Attorney Phone Number:
Defense Attorney:
Defense Attorney Address:
Defense Attorney City, State, Zip:
Defense Attorney Phone Number:

Additional Comments/Special Requests


Independent Medical Evaluation Instructions

Causal Relationship
Necessary and Appropriate Treatment
Maximum Medical Improvement
Diagnosis/Prognosis
Permanent Impairment
Permanency Rating
Physical Restrictions
Pre-existing Conditions

Records to follow by

Email
Disc
US Mail
Overnight
Fax 610.278.0742
Request Account Manager to obtain

 

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