Independent Medical Exam

Your role in this request*

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Your Name*
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Your Email*
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Your Phone Number*
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Estimated number of records in pages*
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Worker Compensation Insurance Company*
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Worker Compensation Insurance Company phone number
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Adjuster name
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Case manager name
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Patient First Name*
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Patient Last Name*
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Patient Phone Number*
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Street Address*
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Street Address
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City*
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State*
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ZIP Code*
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Patient Date of Birth*
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For which of the following is your client seeking an examination?*

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What is the reason for your client’s visit?
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When did this injury occur?*
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Which of the following was the cause of this injury?

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Please specify the cause of the injury*
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What is your client’s preferred appointment location?

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