Independent Medical Evaluations, Inc.
211 Beaumont Place, Traverse City, MI 49684
For clarification, call: (800) 968-4637
FAX - (231) 929-4356

SERVICE INTAKE FORM

BILL TO

 COMPANY
Company Name:

Phone:
Contact: Extension
Email: Fax:
Street: PO Box:
City: State:
Zip Code:
Claim State: Litigated: Yes  No
Travel - How Far? Medical Records # of Inches   
Notification Letter: Yes   No How Soon Evaluation Needed:
Testing: Yes   No Call Verbal: Yes   No
REHABILITATION  DEFENSE ATTORNEY
Company Name: Contact:
Email:
Street PO Box
City: State:
Zip Code: Phone:
Fax: Extension:
Notification Cite Letter: Yes   No State Claims are Handled:
Testing: Yes   No Travel - How Far?
Verbal: Yes   No Litigated: Yes   No
Phone Consultation: Yes   No Trial Date:
How Soon is Evaluation Needed: Amount of Medical Records:

CLAIMANT

  INFORMATION
Name: D.O.B.
Street D.O.I.
PO Box: State Claim Occurred:
City: SS #:
State: Claim #:
Zip Code: Employer:
Phone:
Treating Doctors: Type of Claim:
Notification Cite Letter: Yes   No Chief Complaints:
Type of Services: Dr Specialty Needed:
AMA Guidelines 3rd   4th  5th
Additional Info Needed: Any Forms that need to be filled out:

  OTHER PLAINTIFF/3RD PARTY INFORMATION
Company: Phone:
Contact Person: Extension:
Street Fax:
PO Box Email:
City Notification Cite Letter: Yes   No
State:
Zip Code:
Comments: