Request an appointment

Appointment type*

Independent Medical EvaluationImpairment Rating (based on the 6th Edition of the AMA Guides)File Review
Desired Location*

BillingsGreat FallsHelenaKalispellMissoula
Person Requesting the Appointment*

First NameLast Name
Payer*
Workers' compensation insurer or attorney
How would you like to be contacted regarding the appointment?*

Claim Information

Please provide information regarding the claim being addressed.
Claim number*
Adjuster or attorney if different than scheduling party

First NameLast Name
Date of Onset*

MonthDayYear
Date
Body part(s) to be addressed*
PLEASE NOTE: ANKLE & FOOT INJURIES WILL BE REFERRED ELSEWHERE
Accepted body part(s)*
Nature of injury
What will be addressed at this appointment? Choose all that apply.

Maximum Medical ImprovementImpairment Rating (based on the 6th Edition of the AMA Guides)Return to work and associated restrictions as appropriateCausationClaim and non-claim related diagnosesDiagnostics requestedCurrent and/or future treatmentOther
Additional comments

Is this claim litigated? If so, please include attorney's contact information and any associated deadlines.
How many records are in the file? (Please submit all records at least 10 days prior to the scheduled appointment)

less than 100 pages100-200 pagesmore than 200 pages
Should be Empty:

Demographic Information