Schedule An I.M.E. Online

E-Request Form For Scheduling:

IME       Peer Review       Radiology Review

To schedule any of the above, please complete and submit.
Fields marked with * are required.
(NOTE:  If you are an adjuster already on file with HVMC,
all you need to fill in is your name, company and e-mail address)

ADJUSTER INFORMATION
*Adjuster:

*Company: 

Address:

City:

State:

Zip:
Phone:

Fax:

*E-mail:

Date of Request:

CLAIMANT
*Last Name:

*First Name:

Address:

City:

State:

Zip:

Phone:

Date of Birth:

Soc Sec #:
Date of Loss:

Insured:

*Claim#:

 *Type of Exam:


WCB# (if applicable):

WCB Office (if applicable):


State of Venue:

*This is a:                       Peer Due Date (if applicable):

ATTORNEY:
Name:

Address:

City:

State:

Zip:

Phone:

Fax:

Firm:

TREATING PHYSICIAN: SPECIALTY(S) DESIRED:
Name:

Address:

City:

State:

Zip:

Phone:

Specialty:
#1:

#2:

#3:

#4:

Medicals Will Follow
No Medicals on File

PLEASE CHECK INFORMATION DESIRED: NEED FOR:
Complete History PT
Diagnosis Surgery
Present Complaints Diagnostic Testing
Causal Relationship Massage Therapy
Permanancy Transportation
Section 15/8 (M&S - NYS WC) Medical Supplies
Objective Findings on Exam Household Help
Appropriateness of Current Treatment Other (see comments)
Recommendations for Further Treatment  
Ability to Return to Work  
Degree of Disability (Worker's Comp)  

COMMENTS/INSTRUCTIONS:

Hudson Valley Medical Consultants and HVMC are Service Marks of Daybreak Consulting Services, Inc.

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