Health Claim Resources

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 		IME Referral Form


IME Referral Form

Use this form for online referrals or you may download a copy of this form, fill it out and fax it to us at 410 366-4953.
Referror
Full Name:
Company:
Address:
City:
State:
Zip:
E-mail address:
Hearing Date:
Claimant Information
Name:
Address:
City: 
State:
Zip:
Date of Birth:
Home Phone:
Job Description:
Injury:
Date of Injury:

Insured Data
Insured Name:
Claim Number:
Phone #:
Fax #:
Type:
BI
PIP
Claimant Attorney
Attorney:
Law Firm:
Address:
City:
State:
Zip:
Phone #:
Fax #:
Exam Type
  Chiropractic 
  Dentistry 
  Dermatology
  Ear, Nose & Throat  
  General Surgery
  Internal Medicine/Cardiology
  Neurology
  Opthalmology
  Oral Surgery
  Orthopedic
  Plastic Surgery
  Psychiatric
  Rheumatology
  Urology
  FCE
Other:
 
 
Questions or Instructions to be Addressed: (please check only those that apply)

   Casual Relationship

   History, Diagnosis, Prognosis

   Patient Reached Pre-injury Status?

   Length of Disability

   Work Capacity (Full Duty or Light Duty)

   Medical Treatment Recommendations

Other:

 

 

 

 

 

 

                             

 
© Health Claim Resources
2222 Lake Avenue, Suite 1A • Baltimore, MD 21213
phone: 410-366-4900 • fax: 410-366-4953