Tucker Independent Medical Experts, Inc.
1082 Bower Hill Road, Ste. 100, Pittsburgh, PA 15243
Phone: 412-276-6241 / Fax: 412-265-6530

Request for IME Service Form

To help us serve you, please complete the following form with as much information as possible.  Once you have entered the necessary data in each form field, click "submit" to send us your request.
 
As soon as reasonably practicable after receipt of your request, we will contact you, via your preferred means of communication, to schedule your requested services.
 
 

REFERRAL/RESPONSIBLE PARTY

SCHEDULING PARTY

Check if same as Referral/Responsible Party

IF SERVICE REQUESTED REQUIRES A PHYSICAL EXAMINATION, PLEASE COMPLETE THE FOLLOWING:

EXAMINEE INFORMATION

Gender *
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EXAMINEE / CLAIMANT ATTORNEY INFORMATION

Check if same as Referral/Responsible Party
Is the Examinee Represented?

INJURY INFORMATION

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Will a nurse / case manager and/or attorney be attending the exam with the Examinee?
Does the physician have permission to perform in-office X-rays or other diagnostic tests? *
Note: Testing/x-ray fees are charged in addition to the IME Fee and will be invoiced for separately.
 
 
 Please check and confirm this form is completed and accurate.  Thanks