So that we can efficiently process your request for an IME appointment, please complete the following information. The information will be promptly forwarded to our IME scheduling staff. We will inform you of the date, time, location and physician availability for your IME appointment and will confirm the details of your appointment via email. Click here to review our Policies for the our IME Services.

Please complete this form by entering data in the spaces provided. Use your "tab" key to move throughout the form. Select the "submit" option at the end of the form to submit the data.

Please note "yellow highlighted" fields are required.

1. PATIENT INFORMATION

First Name
Last Name
Middle Initial
Gender
Social Security Number
Birth Month: Birth Day: Birth Year:
Home Address 1
Home Address 2
City
State
Zip Code
Home Phone
Work Phone Work Phone Extension

2. CLAIM INFORMATION

Month of Injury: Date of Injury: Year of Injury:

Type of Injury


Type of Claim

If Other, please describe.

If Work Comp claim, has claim been accepted? Yes No

If yes, what is the accepted injury?

If no, why was the claim denied?

Insurance Carrier

WORKERS COMPENSATION CLAIMS ONLY

Employer
Title/Occupation of Injured
Claim #
Claim Month:	Claim Day:	Claim Year:

3. BILLING INFORMATION/RESPONSIBLE PARTY

BILL TO:

First Name

Last Name

Company

Bill to Address 1

Bill to Address 2

City

State

Zip Code

Work Phone: Work Phone Extension

Fax

4. IME REQUEST

Please indicate your preference of "Physician" and/or "Office Location". Not all physicians perform IMEs at all office locations. Therefore, if you have a strong preference of "Physician", then select the physician’s name and select “No Preference” for the office location.

Conversely, if you prefer an "Office Location" please indicate your preference and select “First Available” or “No Preference” for the physician. We will attempt to accommodate all requests.

Please note, regardless of office location for the IME appointment, all records and correspondence must be directed to the IME corporate office at 5900 Corporate Drive, Suite 200, Pittsburgh, PA 15237.

Preferred IME Physician

Preferred Office Location

The following physicians perform IMEs at the following locations:

Downtown-Dr. McKeating

Fox Chapel/Aspinwall- Drs. S. Kann, J. Kann, Werries, Christoforetti, Adelsheimer, Lieber, Balouris, Biskin, Patti, Hahalyak, and Martone

Kittanning-Dr. Richless

New Kensington-Dr. Richless

North Hills-Drs. Failla, Thomas, Liefeld, S. Kann, J. Kann, Werries, Balouris, Schneider, and Karlik

Robinson Township-Drs. Thomas, Liefeld, Jewell, Langhans, S. Kann, Werries, Christoforetti, Karlik, and Basheda

Seven Fields/Cranberry-Drs. Liefeld, Jewell, Langhans, S. Kann, J. Kann and Werries

Shadyside-Drs. Adelsheimer and Lieber

South Hills-Drs. Karlik and Basheda

Purpose of the IME

Does the IME Physician have permission to perform in office x-rays or other diagnostic tests, if necessary? (Testing/X-ray fees are charged in addition to the IME fee and are to be paid in full.)

This request is for:

Comments/Special Requests

5. REFERRED/SUBMITTED BY
(Will also be the contact we respond back to)

First Name

Last Name

Company

Address 1

Address 2

City

State

Zip Code

Work Phone: Work Phone Extension

Fax

Will a rehab nurse/case manager be attending the IME appointment

If Yes, please fill in Nurse's name:

Before you submit the above request, please print a copy of this form for your records.

Confirmation:
All of the above information is complete and accurate. By submitting this form, I understand the Policies for IME services, including payment requirements.