Physician Panel

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If you already have a MedEx username and password, you can log in to retrieve your referral information and custom cover letter questions. To create a new account, provide a username and password below, and your account will be created when the entire form is submitted. Creating a MedEx account is completely optional, and used only to expedite the process of creating a cover letter and scheduling and IME.

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Referral Information

Name
Company
Address
City
State
Zip Code
Phone	(123-456-7890)
Extension
Fax	(123-456-7890)
Email

Cover Letter Content

Date

(mm/dd/yy)

Claimant Name

Date of Injury

(mm/dd/yy)

Physician Name

Cover Letter Narrative

Special Instructions

Custom Questions

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Optional Questions

	Please provide a diagnosis of this individual's current condition, including any preexisting or degenerative conditions.
	Did a specific event or traumatic work incident directly cause an injury?
	Did a specific event or traumatic work incident temporarily aggravate a preexisting condition?
	Did a specific event or traumatic work incident permanently precipitate, aggravate, or accelerate a preexisting condition beyond normal progression so that this individual will not return to baseline or pre-injury status?
	If a specific event did not occur, is this individual's current condition due to an appreciable period of workplace exposure that was of sufficient frequency, magnitude, and duration to be either the sole cause or a material contributory causative factor in the condition's onset or progression?
	Are this individual's symptoms a manifestation of a non-work-related condition?
	Has all treatment to date been reasonable and necessary with regard to the work injury or work-related condition?
	Has a healing plateau or maximum medical improvement been reached with regard to the work injury or work-related condition? If not, when is a healing plateau/maximum medical improvement anticipated?
	If a healing plateau or maximum medical improvement has not been reached, what further treatment is reasonable and necessary due to the work injury or work-related condition?
	Regardless of causation, what further treatment is reasonable and necessary due to any preexisting or non-work-related conditions?
	Does this individual have any work restrictions related to the claimed work injury or work-related condition? If so, please list each restriction and indicate whether it is permanent or temporary.
	Does this individual have any work restrictions, regardless of causation?
	Has this individual sustained any permanent partial disability as a result of any work injury or work-related condition?
	Regardless of causation, does this individual have any permanent partial disability due to a preexisting or non-work-related condition?
	Does this individual's physical examination reveal any signs of symptom magnification or inconsistencies in objective versus subjective findings?