Us Evaluation Services

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IME - Independent Medical Evaluations, FME - Functional Capacity Evaluations, MRR - Medical Record Reviews
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Personal Information
First Name:

Middle Name:

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Address:

City:

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Business Fax:

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Medical Information
Medical Degree (M.D., D.O., etc.):

Board Certified?


Specialties:

X-Rays, Labs, Testing Performed In-House?:

Other Office Locations (include name, address, and phone):

List Other Doctors at Your Office that May Perform IME's:

Hospital Where You Are On Staff:



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