Evaluation Request Form

Evaluation Request Form

To be completed by the party requesting a QME/AME evaluation or re-evaluation.
Name of Person Submitting Form*

First NameLast Name
Date of Submission*

MonthDayYear
Date
Email Address*
example@example.com
Requested Specialty*
Name of QME/AME*
Panel Number*
Claim Number*
Date of Injury*

MonthDayYear
Date
Relationship to Applicant*
Evaluation Location:*
Note: all evaluations may be done virtually, regardless of location chosen

Applicant Information
Applicant Name*

First NameLast Name
Applicant DOB*

MonthDayYear
Date
Applicant Email
example@example.com
Applicant Phone
Please enter a valid phone number.
Applicant Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is the applicant represented by an attorney?*

YesNoUnknown

Employer Information
Employer Name
Employer Phone
Please enter a valid phone number.
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code

Applicant Attorney Information (Skip if Unrepresented)
Applicant Attorney Name

First NameLast Name
Applicant Attorney Law Firm
Applicant Attorney Phone
Please enter a valid phone number.
Applicant Attorney Fax
Please enter a valid fax number.
Applicant Attorney Email
example@example.com
Applicant Attorney Address

Street Address

Street Address Line 2

CityState

Zip Code

Defense Attorney Information
Defense Attorney Name

First NameLast Name
Defense Attorney Law Firm
Defense Attorney Phone
Please enter a valid phone number.
Defense Attorney Fax
Please enter a valid fax number.
Defense Attorney Email
example@example.com
Defense Attorney Address

Street Address

Street Address Line 2

CityState

Zip Code

Claims Adjuster Information
Claims Adjuster Name*

First NameLast Name
Claims Insurance Company*
Claims Adjuster Phone*
Please enter a valid phone number.
Claims Adjuster Fax
Please enter a valid fax number.
Claims Adjuster Email
example@example.com
Claims Adjuster Address*

Street Address

Street Address Line 2

CityState

Zip Code

Evaluation Request
Does the applicant require an interpreter?*

YesNoUnknown
Does the applicant agree to a remote evaluation?*

YesNoUnknown
Preferred Appointment (if known)
QME appointments are available on Mondays at 11:00 am and 2:00 pm. Other dates and times may be available upon request. Please list the applicant's preferred alternate dates, if known. A confirmation email will be sent within 1 business day.
Additional Notes
Digital Signature*
Should be Empty: