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Independent Medical Evaluation Referral

Requestor Information
Employee/ Claimant Information and Case Details
Case Type
*Services Requested/ Referral Information

(At least one Category must be selected)

    Exam Requests


    *Specific Instructions

    Payer or Adjuster Information
    • Same as Requestor


    Physician Information
    Defense Attorney Information
    • Is there a Defense Attorney

    Claimant Attorney Information
    • Is Claimant represented by an Attorney

    Case Manager Information
    • Is Case Manager assigned

    For any questions contact Erin Sage
    at 585-866-5080

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