Pre-Certification
Disease Management
Medical Bill Audits
IME's/Peer/Film Review
24-Hour Nurses Line
IME's/Peer Film Review

Please fill out the following form. Fields marked with a asterisk (*) are required.

Service(s) Requested: * IME's
Peer Review
Film Review
   
Claim Type: * Auto/PIP
BI
Slip and Fall
Woker's Compensation
Other Claim Type:
   
Choose Treating Physician Specialty. *
Chiropractic
Neurosurgical
Physical Medicine
Psychiatry
Psychology
Dental
Neurology
Orthopedic
Other Physician Specialty: *
   
Issues of Concern: * Causal Relationship
Is current/additonal treatment R&N
Maximum Medical Improvement
Permanency
Impairment Rating
Other Concerns:
   
Referral Information
Referral Name: *
Company: *
Address: *
Address:
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State: *
Zip: *
Phone: *
Extension:
Fax: *
   
claimant/Patient Information
claimant/Patient Name: *
Address: *
Address:*
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State: *
Zip: *
DOB (MM/DD/YYYY): *
DOL (MM/DD/YYYY): *
Phone: *
   
Attorney Information
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Address:
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Zip: *
   
Treating Physician Information
Provider Name: *
Address: *
Address: 
City: *
State: *
Zip: *
Phone: *
Diagnosis: *
   
 
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