IMPORTANT: Data fields marked in red with an asterik [ EG: *Name ] must be filled in or the form will not be accepted.

Your Name

*First:   *Last:  

Company Information

*Name:

Street:

Suite:

City:

State:

Zip:

*Phone:

*Fax:

E-Mail:

Type of Service and Insurance

Select one for type of service:
Please schedule an IME.
Please arrange a peer review.

Select one for type of insurance:
disability
workers compensation
fitness for duty
liability
no fault

Policy details if a disability case (own occup or any occup, etc.): 

Specialty Required

Select one:
psychiatric
psychological
neuropsychological
not sure, please call me
other specialty (record in "Additional Case Info" box at end of form)

If testing is required, please check appropriate boxes below. Note: Testing is typically not available in psychiatric IMEs, and is performed by either a psychologist or a neuropsychologist.

MMPI   WMS   WAIS   BDI  
neuropsychological testing  
rule out malingering evaluation with testing

Appointment and Examinee Information

* Name of Claimant:     

Claimant Phone:     

Occupation:  

Your Reference #:  

Date of Birth (mm/dd/yy):      Social Security #:  

Whom will make claimant appointment notification (check only one)?
We (insurer) will make notification.
Please make notification for us.

*IME Location Desired: ( city and state )   

(Note: If you wish FHIPA to make appointment notification, please supply the claimant's full address in the box below.)

IME Time Line:
schedule for earliest date possible schedule for date in two weeks schedule for date in three weeks schedule for date in one month time line to be determined not applicable, this is a peer review

Present Diagnoses (if known)

Additional Case Information

How were you referred to us?  surfing the net - key word search surfing the net - Yahoo! search surfing the net - a link from another web site referred by another company we are already an FHIPA customer other

  Click here to submit this form.

   Click here to clear this form.