UniMex P.C. IME Request Data Entry Form
Exam Type
Claim Number
WCB Number
Date Of Accident  
Carrier
Name
Address
 
City      
State      
Postal      
Phone      
Fax      
Email
Agent
 
Same as carrier address
First Name/MI  
Last Name    
Address    
     
City    
State    
Postal    
Phone/Ext  
Mobile    
Fax    
Email    
Claimant
First Name/MI  
Last Name    
Employer    
SSN / DOB  
Address    
     
City    
State    
Postal    
County    
Work Phone/Ext  
Home Phone    
Mobile    
Fax    
Email    

Injury Site
Instructions

Specifications

Exam Concerns

1996 Medical Guidelines
2012 Impairment Guidelines
Apportionment
Causal Relationship
Classification
Degree of Disability
Diagnosis
Impairment Rating
Light Duty
M & S 15-8
MMI
Need for Surgery
Need for Treatment
Past Medical History
Permanency
Physical Description
Physical Therapy
Prognosis
Restrictions on RTW
Return to Work
Schedule Loss
Work History

Specialists

Addendum
Anesthesiology
C-4
Cardiologist
Chiropractor
Dentist
Dermatologist
Ear Nose & Throat
Endocrinologist
Family Practioner
File Review
Gastroenterologist
General Surgeon
Gynecologist
Hearing Test
Internal Medicine
MG-2
Neurologist
Neuropsychologist
Neurosurgeon
Occupational Medicine
Opthamologist
Orthopedist
Pain Management
Physical Medicine & Rehabilitation
Plastic Surgeon
Podiatrist
Psychiatrist
Psychology
Pulmonologist
Radiologist Review
Translator
Transportation
Urologist
Vascular Surgeon

Authorized Tests

Other
X-Rays

 

 

 

 

First Name/MI  
Last Name    
Address    
     
City    
State    
Postal    
County    
Phone/Ext  
Fax    
Mobile    
Email

 

 

 

 

Firm Name
Address    
     
City    
State    
Postal    
County    
Phone/Ext  
Fax    
Mobile    
Email

 

 

 

 

  File File Description
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File #3
File #4
File #5