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  IME Request Form  
  Complete as much information below as possible and print a copy for your records. Required fields are bold.
Click 'Submit IME Request' button at the end of the form to securely transmit online,or FAX it to (781) 438-2072.

Scope Medical will contact you within 1-2 business days confirming an appointment.

 
 
 Requestor
 Existing clients only need to fill in adjustor name and company name.
Adjustor's Full Name:
Company:
Street Address:
City:
State: Zip:  
Phone: Fax:
Email
Claimant
First Name:
 Last Name:
SSN/EIN: Date of Birth: mm/dd/yy
Street Address:
City:
State: Zip:
Phone: Alternate Phone:
Claimant's Attorney
Attorney's Full Name
Attorney's Firm:
Attorney's Address:
City:
State: Zip:
Phone: Fax: 
Should Scope Medical Contact Attorney to Schedule Appointment? Yes No
Claim
Type of Case:
Incident Date:  MM/DD/YY Claim #:
    File #:
Insured:
Describe Injury:
Occupation:
Treating Doctor Full Name:
Specialty:
Appointment
Specialty Needed:
 Is it a Reevaluation?
Requested Service: Yes No
Medical Records to be Sent Interpreter Needed?
Films to be Sent Verbal? Yes   No Yes No
No Med. Records Available Stat Date
Needed By 		 MM/DD/YY If 'Yes' - Language?
PLEASE COMMENT ON THE FOLLOWING:  (Select all that apply)
Diagnosis Prognosis Taxi Needed?
Total/Partial Disability Job Description Enclosed Yes No
Causal Relationship Medical End Result Services
History of Injury - Prior Condition Further Treatment Necessary Residuals
Light Duty Restrictions Reasonableness of Fees Work Capacity
Section 36 Loss of Function/Scarring (WC) Treatment Reasonable & Necessary Permanency
Special Requests or Comments to be
Addressed by Doctor
Special Requests or Comments
for Scope Medical
Attachments
Attach up to 10 medical records files to your referral request.
We accept the following file types: doc, pdf, gif, tif, jpg, rtf. File size should not exceed 10MB.
Security Code
Please enter the four letters (any case) displayed:  
Send Referral
If you are uploading files, it may take a few moments to process your form. Please only click submit once.
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