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IME Request
Date of Request: Line of Business:
Requestor: Status:
Requestor email address: Description of Injury Diagnosis...
Claims Office:
Reason for Request...


Information
CLAIM NO: Claimant's ATTORNEY:
D/L: ADDRESS:
EMPLOYEE: PHONE NO:
ADDRESS: IMES REQUESTED:
PHONE #: DRS:
DATE OF BIRTH: Body Parts to be Examined:
SOCIAL SECURITY #: Provider Specialty:
INSURED: Meds will be sent to IME Phys by:
ADDRESS: Defense ATTORNEY:
ADDRESS:
PHONE NO:
Comments:


Check QUESTIONS to be addressed in the IME
1. Diagnosis.
2. Prognosis.
3. Causal relationship to the date of injury.
4. Describe any interim accidents/injuries.
5. Has maximum medical improvement been attained?
6. Is condition related to interim injury/ADL's/natural degeneration of pre-existing condition?
7. Is future treatment in your specialty needed? If so, what type and for how long?
8. Is patient disabled?
9. Is treatment medically reasonable/necessary for these injuries?
10. Would patient receive similar benefit from home exercise program?
11. Explain treatment gaps.
12. Is treatment after gaps medically reasonable/necessary for these injuries?
13. Was testing appropriate so early in the treatment plan?
14. Was diagnostic testing reasonable and medically necessary?
15. Does treatment record support the need for testing/referral?
16. Was correct CPT code used?
17. Did test results alter diagnosis or treatment plan?
18. Were test results incorporated into treatment?
19. Do you agree with conclusion drawn by test results?
20. Is diagnostic testing medically necessary?
21. Do test results correlate clinically with patient's complaints?
22. Will future testing be needed?
23. Does record accurately reflect exam findings/services billed?
24. Is patient able to perform ADL's?
25. Are there any work restrictions?
26. Is there any permanent/partial disability? Percentage?
27. *** Other question
Comments:

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