IME form

Independent Medical Examinations (IMEs)

IMEs are evaluations performed by a physician not involved in the care of the examinee, for clarifying clinical and case issues. IMEs are an important component of workers’ compensation systems, and are also used to clarify other disability or liability associated cases.

Patient Information

First Name(Required)

Last Name(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Birthdate(Required)

Date of Injury

Type of Injury

Type of Case

Worker's Comp

Motor Vehicle

NYS Work Comp

Other

Insurance Information

Insurance Carrier

Contact

First Last

Claim Number

Phone

Fax

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Section Referral Information

(Complete only if different than listed above)

Referral Source

(ie: Case Manager, Vocational Specialist)

Company Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Fax

Phone

Employer Information

Employer Name

Contact

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Physician & Location

All appointments scheduled on a first available basis, unless a specific physician or location is requested.

All physicians do not perform IMEs in all locations. For more information on our physicians and locations, please visit nerehab.com.

Physician or Location Preference

(if any)

Comments

If you are not contacted in 24 business hours regarding this request, call Kathleen Gleason Boyd at 570-344-3788 x315.

IME form

Independent Medical Examinations (IMEs)

Patient Information

Insurance Information

Section Referral Information

Employer Information

Physician & Location

Hassle Free Appointments

* New Patients Only