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Independent Medical Evaluation Referral

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Requestor Information
Employee/ Claimant Information and Case Details
Case Type
*Services Requested/ Referral Information

(At least one Category must be selected)

    Exam Requests

    *Specialty

    *Specific Instructions




    Payer or Adjuster Information
    • Same as Requestor

       

    Physician Information
    Defense Attorney Information
    • Is there a Defense Attorney


    Claimant Attorney Information
    • Is Claimant represented by an Attorney


    Case Manager Information
    • Is Case Manager assigned


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