The PRIME Network Independent Medical Evaluation FormIME/DME FormReferral InformationRequestor Requestor Company Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState/Province Zip/Postal Zip/Postal Address Phone Fax Email Billing InformationContact Name Company Name Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState/Province Zip/Postal Zip/Postal Address Phone Fax Email Claimant InformationName Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState/Province Zip/Postal Zip/Postal Address Phone 1 Phone 2 DOB. Employer Occupation Claim # Date Of Injury/Accident Injury Description Other Complaints Currently Working? Claim Accepted? Jurisdiction Claimant Attorney InformationName Firm Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState/Province Zip/Postal Zip/Postal Address Phone Fax Email Type of ClaimWork WorkAuto AutoDisability DisabilityLiability LiabilityDefense Attorney InformationIs defense attorney assigned? YesNoDefense Attorney Name Firm Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState/Province Zip/Postal Zip/Postal Address Phone Fax Email Cover Letter/Issues to AddressSeparate cover letter to follow Separate cover letter to followHistory of Injury & subsequent treatment History of Injury & subsequent treatmentPrior injuries and/or pre-existing conditions Prior injuries and/or pre-existing conditionsPresent Status Present StatusComprehensive physical exam including non-physiologic findings Comprehensive physical exam including non-physiologic findingsWhether objective findings support the subjective complaint Whether objective findings support the subjective complaintDiagnosis DiagnosisPrognosis PrognosisCan claimant return to work at this time with no restrictions? Can claimant return to work at this time with no restrictions?What are claimant's physical capabilities? What are claimant's physical capabilities?Is claimant at Maximum Medical Improvement? Is claimant at Maximum Medical Improvement?Is there any permanency of injuries or residuals? Is there any permanency of injuries or residuals?Is current treatment reasonable and necessary? Is current treatment reasonable and necessary?Is further treatment needed? If so, what kind, for what length of time and at what frequency? Is further treatment needed? If so, what kind, for what length of time and at what frequency?Causal relationship of the injuries to the accident / incident in question? Causal relationship of the injuries to the accident / incident in question?Appointment InformationSpecialty/Provider Location Appointment Timeframe Report Timeframe Treating Physican(s)Name Name Notification of AppointmentSend appointment letter to patient Send appointment letter to patientRegular Mail Regular MailCertified CertifiedSend appointment letter to Claimant's Attorney only Send appointment letter to Claimant's Attorney onlyCopy to Claimant's Attorney Copy to Claimant's AttorneyCopy to Defense Attorney Copy to Defense AttorneyCopy to Referring Party Copy to Referring PartyCopy to Billing Party Copy to Billing PartyTransportation Needed Transportation NeededTranslator Needed Translator NeededMedical RecordsAre medical records available? Delivery Method Other Issues If you wish to print a copy of your referral request please select “PRINT” before submission.Print FormCaptcha Submit If you are human, leave this field blank.
