IME * Indicates required information. Date January 17, 2019 Name of person sending referral * Your Email * Name of Adjuster * Insurance Company * Insurance Company Address * Adjuster'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 Accident * Claimant's Attorney Claimant's Attorney Address Attorney's Phone Number Please select one * N/F Liability W.C. Other 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 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