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IME Examination OnlyBill ReviewAuditIME # ReschedulesFCEFilm ReviewCost ProjectionImpairmentPermanencyReform ExamPRO
Representative*
Company*
Email Address*
Email address*
Address*
City*
State*
Zip Code*
Phone*
Fax*
Claimant*
Zip*
File/Policy #*
Attorney
Firm name
Contact Attorney
Address
City
State
Zip Code
Phone
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DOL*
DOB*
Insured
Treating Physician
PIPWCBILTDA&H
ChiropracticOrthopedicNeurologyPhysical MedicineInternal MedicinePsychiatryPsychologyDentalTMJ
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Need For TreatmentNeed For Physical TherapyAddress MMIAbility To WorkCausal RelationshipDegree Of ImpairmentPsychologyPermanency
Medical necessity of...
AUDIT: (Physician/Hospital)
Date of Bill
Amount of Bill
Medical Case MgmtVocational MgmtCost ProjectionPre-Certification
Special Instructions
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