Service Request Form
Requesting Party Information
Office Phone Number
Date of Birth (mm/dd/yyyy)
Last 4 of SSN
Date of Injury
Injured Body Part
Nurse Case Manager and Contact Info:
Attorney Name and Contact Info:
If Other Specialty Preference
Type of Claim
If Other Type of Claim
Type of Service
If Other Type of Service
General Cover Letter Questions
What are the patient’s diagnosis and-or diagnoses?
Is the diagnosis causally related to the current injury or accident? Please discuss the etiology for each diagnosis and/or diagnoses?
Is there a history of prior injuries or pre-existing conditions that are impacting the current injury and its treatment thereof? If so, please explain.
Is the current treatment necessary as a result of the current injury or accident?
Can the patient return to work with or without restrictions? If work is restricted, please indicate specific restrictions and duration? Are any current work restrictions anticipated to be permanent?
Has the patient reached a permanent and stationary status? If not, please outline your recommended treatment plan (including type, frequency, duration of treatment, and anticipated date of maximum medical improvement).
Is there objective medical evidence of a permanent impairment? If so, please explain the basis for impairment and rate the percentage of impairment in accordance with the AMA Guidelines?
If stationary, please advise if supportive care is warranted and provide specific recommendations and duration.
Is the patient a surgical candidate? If so, please specify.
If this is a Petition to Reopen, please advise if there are any new, additional, or previously undiscovered medical condition(s) related to the injury that was not present at the time the case was closed. If so, please explain how the industrial injury caused this condition or diagnosis.
Do you have any additional thoughts pertinent to this injury or accident after reviewing the records/performing the examination.
Should be Empty: