IME REQUEST FORM
Adjuster
Company
Address
Address Cont.
City
State
Zip
Date
Phone
Fax
Claimant Name
Address
Address Cont.
City
State
Zip
Social Security Number
Home Phone
Work Phone
Date of Birth
Minor
yes
no
Policyholder
Claim Number
Date Policy Effective
Type
PIP
BI
Other
D.O.I.
Injury
Treating Physician Specialty
Name
Zip
Requested Physician Specialty
Certification
MD
, DO
, DC
, Other
Claimant Attorney
Law Firm
Address
Address Cont.
City
State
Zip
Phone
Fax
Questions or Instructions to be addressed (Please be specific)
MMI
Causal Relationship
Further Treatment
Work Capacity
Interpreter Needed Language
Taxi Needed
Your Email
Home
About Us
Our Services
Contact Us
Referral Forms
Useful Links
Florida Claims Management
21326 Coakley Lane
Land O Lakes, FL 34639
1-800-893-7579
813-948-8801
Email Us
Fax 813-948-8875
