IME * Indicates required field. If box is not applicable, please put NA in the box. Date September 25, 2021 Name of person sending referral * Your Email * Name of Claims Handler * Insurance Co/Agency * Insurance Co/Agency Address * Claims Handler's Phone Number * Claimant's Name * Claimant's Address * Claimant's Phone Number * Claimant's Date of Birth * Insured's Name File Number * Policy Number (if applicable) Date of Loss Claimant's Attorney Claimant's Attorney Address Attorney's Phone Number Please select one * Fit for Duty N/F Liability W.C. Disability Pre-employment Other Please select one: Sec 71 Sec 72 Sec 73 Termination Date If W.C. - WCB# If W.C. - SS# If other: Claimant's Injuries Type of Doctor*: (Select at least one) Acupuncturist Acu/Chiro combo Chiropractor Dental ENT (otolaryngologist) Internist Neurologist Neurosurgeon Orthopedist Pain Management Physiatrist (PM & R) PMR/Acu combo Plastic Surgeon Psychologist Psychiatrist MD If other type of doctor: Treating Doctor Is there a physician you would like us to use? Physician Name: Physician Phone: Comments for the IME Doctor Was the Claimant ever examined by NCEI? Yes No If Yes, NCEI File Number When you press send, you will receive a copy via email. Save Info and submit another IME Request