IME form – Northeast Rehab Associates, P.C.

Independent Medical Examinations (IMEs)

IMEs are evaluations performed by a physician not involved in the care of the examinee, for clarifying clinical and case issues. IMEs are an important component of workers’ compensation systems, and are also used to clarify other disability or liability associated cases.

Patient Information

First Name(Required)

Last Name(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Phone

Birthdate(Required)

Date of Injury

Type of Injury

Worker's CompMotor VehicleNYS Work CompOther

Insurance Information

Insurance Carrier

First

Last

Claim Number

Phone

Fax

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Section Referral Information

Referral Source

(ie: Case Manager, Vocational Specialist)

Company Name

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Fax

Phone

Employer Information

Employer Name

Contact

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone

Fax

Physician & Location

Physician or Location Preference

Comments

If you are not contacted in 24 business hours regarding this request, call Kathleen Gleason Boyd at 570-344-3788 x315.