Nationwide Psychiatric Disability Independent Medical Evaluations, Consulting, & Neuropsychological Testing

The Forest Hills IPA Inc. Security, Reliability & Professionalism


All Purpose IME and Peer Review Referral Form Go Directly to Form	Use to Schedule: * psychiatric IMEs * psychological IMEs * neuropsychological IMEs * peer reviews

If you are an authorized company representative and would like The Forest Hills IPA to set up a psychiatric, psychological, or neuropsychological IME evaluation or peer review, please fill in the form below.

Automatic Confirmation
You will receive automatic confirmation of your request on the computer screen once you submit the form below. If you do not receive confirmation on your screen, please notify us by e-mail or call (718) 786-1328 or (718) 786-4990 if you prefer to submit your IME or peer review referral by phone. You may also send in your request by fax at (718) 937-6529.

Upon submission of this e-mail form, we will also confirm receipt via the phone number furnished. If you have any questions regarding the referral process or would like additional information on FHIPA services, please don't hesitate to contact us.

Regular customers are eligible to have their own individualized referral reform designed with custom data fields available to them at a secure web address.

Sincerely,

Leonard Grossman Ph.D.,
President, The Forest Hills IPA Inc.
Diplomate, The American Board of Forensic Examiners

Where to Send Records, Correspondence, and Payments
The Forest Hills IPA Inc.
45-14 39th Avenue
Sunnyside, NY 11104

Tel (718) 786-1328 Fax (718) 937-6529 email
Our Sunnyside office in New York handles all IME and peer review referrals, scheduling, correspondence, medical records, billing, and provider payments.

IME and Peer Review Referral Form

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 #:

Social Security # (last 4 numbers only please!):
(a partial # is requested to aid in identification so as to avoid scheduling with an examiner who may have once treated the claimant but may not otherwise recall it.)

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:

Present Diagnoses (if known)

Additional Case Information

How were you referred to us?

Click here to submit this form.

Click here to clear this form.

Send site comments here