Service Request Form

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REQUEST	SPECIFICS
* Requesting Company
* Contact Name
* Address
* City
* State
* Zipcode
*Email Address
* Phone Number
Extension
Specialty preference
Physician preference
Location
How soon?
Earliest date that will work
Latest date that will work
Do you need any particular day, time of day, week of the month, etc?

* Type of Evaluation
* Evaluation is for state of
What is the purpose of the IME? eg: Causation, Reasonableness of treatment issues, Return to work, Disability determination.
Special Notes eg: Any special handling instructions? Rush report? Filing deadline?

CLAIMANT	INFORMATION
* Name
* Gender
* Date of Injury
Type of Injury
Address
City
State
Zipcode
Telephone Number
Claim or ID Number
Date of Birth
Social security number
Should PMRI send the claimant a confirmation letter?
Do you want claimant's attorney notified?
If yes, attorney name
Attorney address
Attorney city
Attorney state
Attorney zip

*Note: When faxing this form, please check that all answers are visible. Some field boxes do not show all typed information when printed.

For any problems with form submittal, email skokott@mchsi.com.