Schedule Online | Integrated Medical Evaluations, Inc

Gender:*

Male

Female

State Directed:*

Yes

Transportation Needed:*

Yes

Translation Services Needed:*

Yes

If Yes, please specify the language requested for Translation:

Reason for IME/Service Request*

Causation/Reasonable and Related Medical Care

Maximum Medical Improvement

Impairment Rating

Prognosis & Treatment Plan

Work Disability Status

Reasonable Medical Costs

Requested Specialty:*

Claim Type:*

Worker's Compensation

Auto

General Liability

Disability

Additional Information Regarding Requested Service(s) and/or Specialty:

Service Type:*

IME

Record Review

Requested by First Name:*

Requested by Last Name:*

Company Phone Number:*

Related Party First Name:

Related Party Last Name:

Related Party Address:

Related Party State:

Related Party Email Address:

Related Party Phone Number:

Deadline And/Or Important Date:

Notes Regarding Specified Date:

Primary Office Name*

Primary Office Address*

Primary Office Phone*

Primary Office Email*

Delivery Method of Medical Records

Fax

FedEx/UPS

FTP

If mailing address is different than above:

Medical Specialty or Area of Focus*

Board Certification

Yes

Medical Specialty or Area of Focus*

Board Certification

Yes

Medical Specialty or Area of Focus*

Board Certification

Yes

Medical License State*

License Expiration Date*

Medical License File Upload

IME Programs

ABIME

CIME

AMA Guideline Edition(s)

Willing to Speak at Conferences

Yes

How long have you performed IMEs?*

Willing to Testify

Yes