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Work Comp IME Request Form
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* Indicates required question
Requestor Name
*
Your answer
Requestor Phone Number
*
Your answer
Requestor Email Address
*
Your answer
Assigned Adjuster Name
*
Your answer
Assigned Adjuster Email Address
*
Your answer
Assigned Adjuster Phone Number
*
Your answer
Injured Worker Name
*
Your answer
Injured Mailing Address
*
Your answer
Injured Date of Birth
*
MM
/
DD
/
YYYY
Injured Date of Injury
*
MM
/
DD
/
YYYY
Injured SSN (if NA, email copy of C4)
*
Your answer
Claim Number:
*
Your answer
Employer
*
Your answer
Injured Body Parts within Claim
*
Your answer
Injured Body Parts to be Examined during IME
*
Your answer
Purpose for IME
*
Your answer
Accepted Body Parts on Claim (not for the IME)
*
Your answer
If the body part or condition is denied, please provide additional comments regarding denial.
Your answer
Any known prior work comp injury
*
If yes, please provide date of injury and body part. If no, please type N/A or unknown
Your answer
Which Provider are you requesting
*
Choose
Dr. John M. Baldauf
Dr. Hugh L. Bassewitz
Dr. Thomas Dunn
Dr. Roger A. Fontes
Dr. Matthew N. Fouse
Dr. Kyle Hancock
Dr. Chad M. Hanson
Dr. Lawrence R. Huff
Dr. Parminder S. Kang
Dr. Andrew B. Kim
Dr. Daniel D. Lee
Dr. Michael L. Lee
Dr. Michael Miao
Dr. Russell T. Nevins
Dr. Steven K. Nishiyama
Dr. Amit H. Parekh
Dr. S. Andrew Park
Dr. Archie C. Perry
Dr. Abdi Raissi
Dr. Walter Song
Dr. Timothy B. Sutherland
Dr. Craig T. Tingey
Dr. Troy S. Watson
Dr. Richard P. Winder
Dr. Richard Woodworth
Dr. Jessica R. Zarndt
Has the injured worker been seen by another physician
*
Yes
No
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