IME Request Form

Save for later

Please fill in all the required fields to request an IME from us. You are able to save your entries and continue later. Check your dashboard to view all forms and status of IMEs already booked.

1 The Case

2 The Claimant

3 Attorneys & Doctors

4 The IME

Tell us about the Claimant
Please fill in all fields
- Claimant's Name
- Job Title
- Date of Birth
  Date Format: MM slash DD slash YYYY
- Phone Number
- Phone Number 2
- Address - (Label not used)
  Home Address Address Line 2 City State ZIP Code

The Attorney
Please fill in all fields
- Name of Attorney
- Phone
- Fax
- Address (label not used)
  Address Address Line 2 City State ZIP Code
Treating Doctors

List

Name of Doctor	Phone	Fax	Address	Address Line 2	City	State	Zip Code
Doctor Remove this Doctor

IME Request Form

Tell us about your case

Tell us about the Claimant

The Attorney

Treating Doctors

About the IME