IME PHYSICIAN INFORMATION SUBMISSION FORM INDEPENDENT MEDICAL EVALUATIONS, INC.

NAME:

MD/DO/DC/DDS/OTHER:

DBA/INC/PC:

FIRM:

ADDRESS:

WPHONE:

ADDRESS LINE 2:

FAX:

CITY, STATE, ZIP

EMAIL:

FIELD SPECIALTY:

BOARD CERTIFICATIONS:

STATES LICENSED IN:

RESIDENCE:

OFFICE MANAGER:

PHONE:

PHONE/CELL:

ARE X RAYS DONE IN HOUSE?

CLINIC LOCATIONS UNDER CONSIDERATION:

PHONE CONSULTATION 15 MINS:

ARE YOU WILLING TO TRAVEL?

DEPOSITION FEE:

COST PER IME:

OTHER FEES:

CHART REVIEW FEE:

LIVE TESTIMONY:

WE ASK YOU TO USE OUR TRANSCRIPTION SERVICE:

CLINIC LOCATIONS:

PLEASE PROVIDE CLINIC NAMES, ADDRESS, PHONE, FAX & EMAIL FOR ALL LANGUAGES

CRITERIA: We need a copy of your license, liability insurance and a copy of your resume. Please mail to our

Corporate Office - IME, INC, 211 Beaumont Pl., Traverse City, MI 49684 or fax to (231) 929-4356

ARE THERE OTHER DOCTORS IN YOUR ORGANIZATION THAT PERFORM IMEs?

HISTORY OF DOING MEDICAL/LEGAL AND NUMBER OF YEARS: