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
Not required for repeat users - unless you need to submit new information
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.
If there is a known ext# , please indicate in other contact information below
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 firstname.lastname@example.org.
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