The PRIME Network Independent Medical Evaluation Form
Referral Information
Billing Information
Requestor
Requestor Company
Address
Address
City/State/Zip
Phone
Fax
E-Mail
Contact Name
Company Name
Address
Address
City/State/Zip
Phone
Fax
E-Mail
Patient Information
Patient Attorney Information
Name
Address
City/State/Zip
Phone 1
Phone 2
Soc. Sec. #
DOB.
Employer
Occupation
Claim#
Date of Injury/Accident
Injury Description
Other Complaints
Currently Working?
Claim Accepted?
Jurisdiction
Type of Claim
Name
Firm
Address 1
Address 2
City/State/Zip
Phone
Fax
E-Mail


Defense Attorney Information
Is Def. Attorney Assigned
Def. Attorney Name
Firm
Address
Address
City/State/Zip
Phone
Fax
Cover Letter / Issues to Address Appointment Information
Separate cover letter to follow
History of Injury & subsequent treatment
Prior injuries and/or pre-existing conditions
Present Status
Comprehensive physical exam including non-physiologic findings
Whether objective findings support the subjective complaint
Diagnosis
Prognosis
Can claimant return to work at this time with no restrictions?
What are claimant's physical capabilities?
Is claimant at Maximum Medical Improvement?
Is there any permanency of injuries or residuals?
Is current treatment reasonable and necessary?
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?
Contact for Input?

Medical Records
Are Medical Records Available?
Delivery Method
Specialty/Provider
Location
Appointment Timeframe
Report Timeframe
Treating Physican (s)
   Name
Name

Notification of Appointment

Send appointment letter to patient                   

Regular Mail                           Certified         
Send appointment letter to Claimant's Attorney only
Copy to Claimant's Attorney
Copy to Defense Attorney
Copy to Referring Party
Copy to Billing Party
Transportation Needed
Translator Needed

 
 
Other Issues
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NOTE: If you wish to print a copy of your referral request, please select 'Print' before submission.