Date of Letter
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Month
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Day
Year
Date
Person Writing the Letter
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First Name
Last Name
Name of the Company You Work For
Email Address(es) to Receive a Copy of This Letter
*
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Claim Information
Please enter the information for the injured person being evaluated.
Injured Person's Name
*
First Name
Last Name
Date of Birth
*
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Claim Number
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Date of Onset
*
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Month
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Day
Year
Date
Body Part(s) to be Addressed
*
Accepted Body Part(s), if Any
*
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Introductory paragraph (include a history of the injury/disease and the main issues to be addressed in the IME that are not listed already below)
*
Please review the medical notes and address the following questions on a medically more probable than not basis with a reasonable degree of medical certainty. Check all that apply, as appropriate:
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List all claim-related and non-claim-related diagnoses.
Describe how the claim-related diagnoses were caused by the compensable injury/occupational disease.
For any claim related diagnoses, list the subjective and objective findings and comment on whether subjective complaints are consistent with the objective findings.
Is further medical treatment warranted? Outline treatment recommendations for the claim related conditions.
Is the individual’s current treatment consistent with the Montana Utilization and Treatment Guidelines?
What are current physical restrictions for the claim related diagnoses? Are these temporary or permanent restrictions?
Is the individual capable of returning to their time of injury job?
Is the individual at maximum medical improvement (MMI)? If not, when is MMI anticipated?
If indicated, determine the appropriate whole person impairment rating, according to the AMA Guides, 6th Edition.
Optional: Additional Question 1.
Optional: Additional Question 2.
Optional: Additional Question 3.
Information regarding the claim
Include any other information pertinent to this claim here.
I authorize all necessary diagnostic testing in conjunction with this IME
Authorized
Please contact me for authorization
By submitting this form, I (as the person listed on the previous page) authorize REOH to use these questions as the cover letter to be addressed in the appointment for this injured person.
*
Verified
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Should be Empty: