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ANCILLARY SERVICES REFERRAL FORM

To download this form click here.

Purpose of Request

IME Examination OnlyIME Examination OnlyBill ReviewAuditIME # ReschedulesFCEFilm ReviewCost ProjectionImpairmentPermanencyReform ExamPRO

Representative

Representative*

Company*

Email Address*

Email address*

Address*

City*

State*

Zip Code*

Phone*

Fax*

Claimant

Claimant*

Address*

City*

State*

Zip*

Phone*

File/Policy #*

Attorney

Firm name

Contact Attorney

Address

City

State

Zip Code

Phone

Employer

Phone

DOL*

DOB*

Insured

Treating Physician

Address

City

State

Zip Code

Phone

Type of insurance

PIPWCBILTDA&H

Type of Exam

ChiropracticOrthopedicNeurologyPhysical MedicineInternal MedicinePsychiatryPsychologyDentalTMJ

Other (Please Specify)

Items which need to be addressed

Need For TreatmentNeed For Physical TherapyAddress MMIAbility To WorkCausal RelationshipDegree Of ImpairmentPsychologyPermanency

Other (Please Specify)

Medical necessity of...

Please complete the following section for Audit, Disability Case Management, Pre-certification or Cost Projection Referrals only

AUDIT: (Physician/Hospital)

Date of Bill

Amount of Bill

Medical Case MgmtVocational MgmtCost ProjectionPre-Certification

Special Instructions

973-257-5200

info@firstmco.com

Headquarters:

2740 Route 10 West
Suite 304
Morris Plains, NJ 07950

Branch Office:

Office Center Drive
Fort Washington, PA 19034
Ph: 800 247-3422
Fax: 267 513-1984

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