Appointment Request Form

So that we can efficiently process your request for an IME appointment, please complete the following information. The information will be promptly forwarded to our IME scheduling staff. We will inform you of the date, time, location and physician availability for your IME appointment and will confirm the details of your appointment via email. Click here to review our Policies for our IME Services.

Please complete this form by entering data in the spaces provided. Use your "tab" key to move throughout the form. Select the "submit" option at the end of the form to submit the data.

Please note “*” fields are required.

PATIENT INFORMATION

First Name *

Middle Initial

Last Name *

Gender

Social Security Number *

Birthday (MM/DD/YYYY) *

Home Address 1 *

Home Address 2

City *

State *

Zip Code *

Home Phone *

Work Phone

EXT

CLAIM INFORMATION

Injury Date * +

Type of Injury *

If multiple, please list additional

If other, please specify

Claim Type *

If other please describe.

If Work Comp, has claim been accepted?

Yes

No

If yes, what is the accepted injury?

If no, why was the claim denied?

Insurance Carrier

WORKERS COMPENSATION CLAIMS ONLY

Employer

Title\Occupation of Injured

Claim Number

Claim Date +

Claim Jurisdiction *

BILLING INFORMATION/RESPONSIBLE PARTY

First Name *

Last Name *

Company *

Bill to Address 1 *

Bill to Address 2

City *

State *

Zip Code *

Work Phone *

EXT

Fax

Email Address *

IME REQUEST

Please indicate your preference of "Physician" and/or "Office Location". Not all physicians perform IMEs at all office locations. Therefore, if you have a strong preference of "Physician", then select the physician’s name and select “No Preference” for the office location.

Conversely, if you prefer an "Office Location" please indicate your preference and select “First Available” or “No Preference” for the physician. We will attempt to accommodate all requests.

Please note, regardless of office location for the IME appointment, all records and correspondence must be directed to the IME corporate office at 5900 Corporate Drive, Suite 200, Pittsburgh, PA 15237.

Preferred IME Physician *

Preferred Office Location *

The following physicians perform IMEs at the following locations:

Downtown-Dr. McKeating
Fox Chapel- Drs. S. Kann, J. Kann, Werries, Pagnotto, Adelsheimer, Lieber, Balouris, Emond, and Hahalyak
Kittanning-Dr. Richless
New Kensington-Dr. Richless
North Hills-Drs. Thomas, Liefeld, Jewell, S. Kann, J. Kann, Werries, Balouris, Emond, Pagnotto, Campbell, Schneider, and Karlik
Robinson Township-Drs. Thomas, Liefeld, Jewell, Langhans, S. Kann, J. Kann, Werries, Emond, Pagnotto, Campbell, Karlik, and Basheda
Seven Fields/Cranberry-Drs. Liefeld, Jewell, Langhans, S. Kann, J. Kann, Emond, Pagnotto, Werries, and Campbell
South Hills-Drs. Karlik and Basheda

Purpose of the IME

Does the IME Physician have permission to perform in office x-rays or other diagnostic tests, if necessary? *

(Testing/X-ray fees are charged in addition to the IME fee and are to be paid in full.)

This request is for: *

Comments/Special Requests

REFERRED/SUBMITTED BY

(Will also be the contact we respond back to)

First Name *

Last Name *

Company *

Street Address *

Address Line 2

City *

State *

Zip Code *

Work Phone *

EXT

Fax

Email Address *

Will a rehab nurse/case manager be attending the IME appointment?

Yes

No

If yes, Nurse's name

How do you want the report/invoice sent? *

Mail

E-mail

Enter the word in the image *
captcha

Before you submit the above request, please print a copy of this form for your records.

Confirmation:
All of the above information is complete and accurate. By submitting this form, I understand the Policies for IME services, including payment requirements.