Patient Demographics
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Male
Female
Other
Decline
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Type of Phone
Home
Office
Cell
Email
*
example@example.com
Appointment Information
Case Type
*
Workers' Compensation
Motor Vehicle Accident
Premises Liability
Date of Accident
*
-
Month
-
Day
Year
Date
Appointment Type
IME
Evaluation/Treatment
ATP
Yes
No
Georgia Claim?
Yes
No
PPD Rating (IME only)
Yes
No
Payment Type
Health Insurance
Funding
Lien
Payment Type
Health Insurance
Funding
Preferred Funding Company
Health Insurance Company & Member ID Number
Body Part(s) To Be Evaluated
*
Attorney Information
Attorney Name
*
First Name
Last Name
Attorney Phone Number
*
-
Area Code
Phone Number
Attorney Fax
*
-
Area Code
Phone Number
Attorney Email
*
example@example.com
Assistant/Paralegal
First Name
Last Name
Insurance Information
**Please provide ONLY 1st Party Payer Information. We do NOT file 3rd Party**
Insurance Carrier
Claim Number
Adjuster Name
First Name
Last Name
Adjuster Phone Number
-
Area Code
Phone Number
Adjuster Fax Number
-
Area Code
Phone Number
Adjuster Email
example@example.com
Claims Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please upload any/all Medical Records pertinent to the case
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