Home MedTrak Services Healthcare Professionals Our Company MedNet Quick Referral Form Please Check One: IME File Review Company Information Company Name: * City: Address: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconson Wyoming   Zip: Adjuster: First Name: * Phone #: * Last Name: * Fax #: Office: Email: Case Manager: First Name: Phone: Last Name: Fax: Office: Email: Claimant Information First Name: * Address: Last Name: *   Claim #: * City: DOL: (03/09/2004) * State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconson Wyoming DOB: (03/09/2004) * Zip Code: SSN: Phone #: State Directed: Check if this is a state directed service Transportation: No Yes Translation: No Yes Please enter the Language you need for Translation: (Do not enter English) Treating Physician First Name:   Diagnosis: * Last Name: Claimant Attorney First Name: Phone #: Last Name: Address: City:     State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconson Wyoming   Zip: Requested Physician Is there a Physician you would like us to use? Physician: Phone #: Requested Specialty: Chiropractic Neurologist Neurosurgeon Orthopedic Physical Medicine Psychiatrist (MD) Psychologist Osteopath (DO) Other  Reasons For IME: Causally Related Maximum Medical Improvement Impairment Rating Prognosis & Treatment Plan Apportionment Work Disability Status Reasons For Review: Causally Related Treatment Length / Frequency / Modalities Necessity of Diagnostic Tests Review Proposed Treatment Need for Continued Treatment Charges for Treatment Please specify any additional information or questions: Copyright 2004 MedNet IMS, Inc. All Rights Reserved. P.O. Box 957929 - Duluth, GA 30095       1-800-789-6847