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.

Type of service requested *

REFERRAL/RESPONSIBLE PARTY

Referring Source

Referring Company

Referring Address1

Referring Address2

Referring City

Referring State

Referring Zip

Referring Phone

Referring Fax

Referring Email

SCHEDULING PARTY

Check if same as Referral/Responsible Party

YES

Contact Name

Company Name

Scheduling Address1

Scheduling Address2

Scheduling City

Scheduling State

Scheduling Zip

Scheduling Phone

Scheduling Fax

Scheduling Email

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

Physician Specialty

If other, please specify

EXAMINEE INFORMATION

Name *

Gender *

Male

Female

Examinee Address

Examinee City

Examinee State

Examinee Zip

Home Phone

Work Phone

D.O.B +

EXAMINEE / CLAIMANT ATTORNEY INFORMATION

Check if same as Referral/Responsible Party

YES

Is the Examinee Represented?

Yes

Examinee's Attorney Name

Firm Name

Attorney Address

Attorney City

Attorney State

Attorney Zip

Attorney Phone

Attorney Fax

Attorney Email

INJURY INFORMATION

Injured Areas *

Date of Injury +

Type of Injury

If Workers' Compensation, what is/are the accepted injury(ies)?

Employer

Occupation

Claim Number

How do you prefer to receive your appointment / terms of engagement confirmation letter?

Will a nurse / case manager and/or attorney be attending the exam with the Examinee?

Yes

If yes, please indicate whom

Does the physician have permission to perform in-office X-rays or other diagnostic tests? *

Yes

Note: Testing/x-ray fees are charged in addition to the IME Fee and will be invoiced for separately.

If this is your first visit, how did you hear about us?

If referral or other, please specify

Additional Information/Comments/Special Requests/Deadlines

Please check and confirm this form is completed and accurate. Thanks