Wufoo

Referral form

IME Request IME Re-Exam PEER Request

Indicate the service you need to request. All 2nd opinion exams are to considered an IME for purposes of this request form. A "Re-Exam" is if the doctor has already seen the examinee and a follow up is necessary. "Peer" if you need a review of records performed.
*

This is required so we may send a confirmation to you
Adjuster's address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Not required for repeat users - unless you need to submit new information
Phone ### - ### - ####
Fax
### - ### - ####
Only required if you need this indicated on appointment letters and other contact information being sent on your behalf
If the insured is the same person as the examinee you do not need to complete this area.
Claimant / Examinee information
Date of Birth MM / DD / YYYY
Clmt's Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Clmt's Home Phone ### - ### - ####
Clmt Cell Phone ### - ### - ####
Clmt Work Phone ### - ### - ####
If there is a known ext# , please indicate in other contact information below
Specialty Requested
Click all that apply
Chiro - D.C. Medical Doctor - MD Ortho Neuro PMR Accu - AP/DOM/LaC D.O. (indicate specialty below if appicable) Other
Issues to Address:
Click all that apply
Causal Relationship Diagnosis Prognosis Further Treatment Info Work Restrictions Disability, if applicable Discuss if addl. care is r/n/r
Upload your medical records here...

Attach your medical records here if available in an electronic format. Should you need more than 3 files/uploads, feel free to email them to service@certifiedmed.com.
Attorney info if applicable
Atty's Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Atty Phone ### - ### - ####
Atty Fax ### - ### - ####
Additional Information regarding request/clmt/injuries/topics, etc....

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Do Not Fill This Out

Wufoo

Referral form

Claimant / Examinee information

Attorney info if applicable