Schedule an IME Service

Saving and Retrieving Referral Information

If you plan on completing this form multiple times, you can provide a username and password below, and MedEx will save your input for the Referral Information section of the form. After providing your username and password, please continue filling out the form, and your account will be created when the form is submitted. You can retrieve this information by logging in here. The Referral Information section will then be filled in with the values that you used previously.

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Referral Information

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

Service Information

Service Type	Independent Medical Evaluation Record Review Supplemental Report Deposition
Case Type	Worker's Compensation Personal Injury / No-Fault Disability / Malpractice Other
Doctor Specialty
Doctor Preference
Scheduling Timeframe	(IME Calendar - Opens in new window)
Report Due Date (if any)	(mm/dd/yy)
Will a nurse case manager be attending the IME appointment?
	Yes(nurse's name) No
Special Instructions
Will you be utilizing our cover letter service?
	Yes No

Claimant Information

First Name
Last Name
Gender	Male Female
Address
City
State
Zip Code
Phone	(123-456-7890)
Birth Date	(mm/dd/yy)
SSN	(123-45-6789)
Type of Injury
Date of Injury	(mm/dd/yy)
Claim Number
Claim State	Wisconsin Claim Minnesota Claim Other
Employer
Treating Practitioner
Attorney
Would you like us to send the claimant a reminder letter and location map one week prior to the IME?
	Yes No
Would you like us to call the claimant with an appointment reminder three days prior to the IME?
	Yes No

Additional Information

How did you hear about MedEx?
	Current Client Previous Client Referred By
Scheduling Confirmation	Email Fax Phone

Human Challenge

Please check the box below. Doing this helps prevent automated programs from abusing this service. If you plan to fill out this form multiple times, you can bypass this "Human Challenge" in the future by creating an account at the top of this page.