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		NOTE: USE TAB KEY FOR NAVIGATING BETWEEN FIELDS
Company Name:		Phone:
Contact:		Extension
Email:		Fax:
Street:		PO Box:
City:		State:	State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam 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 Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
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Claim State:	State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam 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 Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming	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		NOTE: USE TAB KEY FOR NAVIGATING BETWEEN FIELDS
Company Name:		Contact:
		Email:
Street		PO Box
City:		State:	State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam 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 Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:		Phone:
Fax:		Extension:
Notification Cite Letter:	Yes   No	State Claims are Handled:	State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam 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 Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
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		NOTE: USE TAB KEY FOR NAVIGATING BETWEEN FIELDS
Name:		D.O.B.
Street		D.O.I.
PO Box:		State Claim Occurred:	State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam 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 Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
City:		SS #:
State:	State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam 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 Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming	Claim #:
Zip Code:		Employer:
Phone:
Treating Doctors:		Type of Claim:
Notification Cite Letter:	Yes   No	Chief Complaints:
Type of Services:		Dr Specialty Needed:	-- SELECT SPECIALIST NEEDED -- ACUPURCTURIST AEOGOLOGIST ADDICTIOLOGIST ALGOLOGIST ALLERGIST ANESTHESIOLOGIST AUDIOLOGIST BIOMECHANICAL ENGINEER CARDIOLOGIST CARDIOVASCULAR SURGERY CHIROPRACTOR CLINICAL PHARMACOLOGIST DERMATOLOGIST DENTIST TMJ SPECIALIST EMERGENCY MEDICINE ENDOCRINOLOGIST GERENTOLOGIST GYNECOLOGIST GENERAL SURGERY HAND SPECIALIST HEMATOLOGIST HERNIOLOGIST HOMOPATHIC MEDICINE INFECTIOUS DISEASES INTERNIST INDUSTRIAL MEDICINE OCCUPATIONAL MEDICINE NEONATOLOGIST NEUROLOGIST NEURO-OPTHALMOLOGIST NEPHROLOGIST NEUROPSYCHOLOGIST NEUROPATHOLOGIST NEUROSURGERY NERUORADIOLOGIST MANAGED CARE NURSE LEGAL NURSE CONSULTANT OTOLARYNGOLOGIST OTORHINOLARYNGOLOGIST OCCUPATIONAL THERAPIST ORAL & MAXILLOFACIAL SURGERY OBSTETRICS OPHTHALMOLOGIST ORTHOPEDIST ONCOLOGIST PATHOLOGY PATHOLOGIST (CHEMICAL) PEDIATRIC CARDIOLOGIST PEDIATRIC ALLERGIST PEDIATRICS PHYSICIAL MEDICINE PODIATRIST PLASTIC SURGERY PSYCHIATRY PSYCHOLOGY PULMONARY MEDICINE PEDIATRIC PULMONARY PEDIATRIC NEUROPSYCHOLOGIST PEDIATRIC NEUROLOGIST PEDIATRIC ORTHOPEDICS PHYSICAL THERAPIST RADIOLOGIST RHEUMATOLOGIST THORACIC SURGERY TOXICOLOGIST UROLOGIST VASCULAR SURGERY
AMA Guidelines	3rd   4th  5th
Additional Info Needed:		Any Forms that need to be filled out:
OTHER PLAINTIFF/3RD PARTY INFORMATION			NOTE: USE TAB KEY FOR NAVIGATING BETWEEN FIELDS
Company:		Phone:
Contact Person:		Extension:
Street		Fax:
PO Box		Email:
City		Notification Cite Letter:	Yes   No
State:	State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam 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 Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Comments:

IME, Inc. Home

Independent Medical Evaluations, Inc. Corporate Office
IME, Inc.
211 Beaumont Place
Traverse City, Michigan-MI, USA 49684
Phone: (231) 929-1474
Toll-Free: (800) 968-4637
Fax: (231) 929-4356
Email: info@imei.com