IME/File Review Services Form

Please fill in the form below to submit your request. *NOTE* all submissions are sent to us secure and are HIPAA compliant.

Date of Request
IME Or Records Review	IME:        |    Records Review:
Requesting Attorney Name
Requesting Attorney Firm
Requesting Attorney Address
Requesting Attorney City/State/Zip
Requesting Attorney Email
Requesting Attorney Phone
Paralegal's Name
Paralegal's Email
Paralegal's Phone
Claimant's Full Name
Claimant's Sex	Male: |    Female:
Claimant's Date Of Birth
Reference Case No.
Claim No.
Date of Loss
Opposing Attorney Name
Opposing Attorney Firm
Opposing Attorney Address
Opposing Attorney City/State/Zip
Opposing Attorney Email
Opposing Attorney Phone
Opposing Attorney Paralegal
Opposing Attorney Paralegal Email
County/Location for Exam
Report Due Date
Consultant and Specialty
Would you like copy of CV?	Yes: |    No:
Issues or Injuries
Trial Date
Arbitration Date
Consultant Testimony – Requested Date
Discovery Cutoff Date
Status of Records
Size of File (inches or page count)
If billing, Insurance Adjuster Name
If billing, Insurance Adjuster Email
If billing, Claim Number
Additional Information / Comments