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Company Information:
*Company's Name
*Representative
*Phone Number
*Address
*City
*State/Zip
---
AK
AL
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*Email Address
Attorney’s Information:
Attorney’s Name
Attorneys Phone Number
Attorney’s Fax Number
Attorney Address
Attorney’s City
Attornye's State/Zip
---
AK
AL
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Claim Information:
*Claim Number
*Claimant Name
*Date of Birth
*Date of Loss
*Address
*City
*State/Zip
---
AK
AL
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Claimant Phone Number
Claimant Cell Phone Number
Claimant Work Phone Number
Policy Number
Policy Holder
Policy State
---
AK
AL
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Gender:
Male
Female
Minor:
Yes
No
(if yes) Guardian’s name
Treating Provider’s Information:
Provider Name
Specialty
Phone Number
Fax Number
Address
City
State/Zip
---
AK
AL
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Employer Information (Work Comp Cases Only):
Employers Name
Phone Number
Fax Number
Address
City
State/Zip
---
AK
AL
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Additional Claimant Information (Same DOL):
Claim Number
DOL:
Gender:
Male
Female
Claimant’s Address
Claimant’s City
State/Zip
---
AK
AL
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Policy Number
Policy State
---
AK
AL
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Claimant’s Name
Date of Birth
Phone Number
Cell Phone
Minor:
Yes
No
(if yes) Guardian’s name
Policy Holder
Comments:
Service Information:
IME
Peer Review
Radiology
PIP
MedPay
BI
Disability
WC
Specialty
Transportation:
Yes
No
Translation:
Yes
No
Language
Auto Reschedule:
Yes
No
ADDITIONAL SERVICE TYPE:
SERVICE TYPE:
IME
Peer Review
Radiology Review
Specialty
Additional Service Type:
IME
Peer Review
Radiology Review
Specialty
Items to address:
Causal Relationship
Further Diagnostic Testing
Need for Further Treatment
Occupational Status
Schedule Loss of Use
Massage Therapy Needed
Degree of Disability
Necessity of Surgery
Need for Household Help
Permanency
Activity Restriction
Past Treatment Recommendations
Frequency/Duration of treatment
Need for durable medical equipment
Need for Transportation
Prognosis
Diagnosis
Target return date to work
Medical Records:
Upload Medical Records
No Medical Records Available
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