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IME - Independent Medical Evaluations, FME - Functional Capacity Evaluations, MRR - Medical Record Reviews
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Request Forms for Clients

Please select, complete, and submit the appropriate request form.
Please choose and click on a form from the selections below:

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CLAIMANT INFORMATION
First Name:

Middle Name:

Last Name:

Address 1:

Address 2:

City:

State:

Zip Code:

Date of Birth (mm/dd/yyyy):
/ /
Phone:

Email:



CLAIM INFORMATION
Claim #:

Type of Claim:

Employer:

Occupation:

Date of Loss (mm/dd/yy):
/ /
Last Day Worked (mm/dd/yy):
/ /
Treating Physician / Therapist(s):

Diagnosis:

Comments:


IME APPOINTMENT INFORMATION
Specialty Requested:

Verbal Report?

Sending Medical Records to US Evaluation Services?

*Please send all correspondence to U.S. Evaluation Services. A cover letter is required from the requesting party to ensure we have all instructions for the IME requested.


CLAIMANT NOTIFICATION
Claimant to be Notified by U.S. Evaluation Services?
If Yes, List Method:

REQUESTING PARTY INFORMATION
Requested By:

Company Name:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Email:






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