Independent Medical Evaluation Request

Note: To download the IME request form to fill in electronically or by hand, for fax or mail submission, click here. You can also submit the request electronically below:

Requestor's Name:
Requestor's Email:
Date:
Acct #:
Phone #:      Ext.:
Fax #:

1. Please arrange an appointment for:
Policy #:      Claim #:      SS #:
Claimant: M F
Date of Birth:
    Address
     Street:
     City:           State / Province:           Zip:
     Country:
Phone #:
Occupation:
Employer:      Length of Service: years
Type of Policy:
Date of Disability:
Nature of Disability:

2. Physicians not to be used for this examination such as attending physician or previous medical examiners:

3. Type of Specialist required:

4. If you wish to set a maximum fee, state physician's fee:
Testing fee:

5. Do you wish PAS to write letters to the physician and the claimant?	Yes No
6. Do you wish PAS to phone you wish the appointment information prior to mailing of your written confirmation?	Yes No
7. Do you want the claimant's letter sent by certified mail (Return-Receipt)?	Yes No
8. If possible, do you want this examination scheduled for earlier than 2 weeks and physician/claimant correspondence sent by express mail?	Yes No
9. Will you be forwarding claimant's medical records?	Yes No

10. Instructions or policy definitions to be given special attention by the examining physician: