IME Services, Inc.

Service Request Form
(Once Submitted this form will be sent to ime@ime-services.com)

Please provide as much information as possible. Any fields that are marked as required (*)can not be left blank. Once completed you may click the Submit button at the bottom of the page and your request will be processed immediately. If you have any questions you may contact our office at Phone:(631) 392-1001  / Fax:(631) 392-1504.

Requestor Information
*Name*Company NAIC / #:

Address City State Zip

*Phone Ext Fax Email

Claimant Information
*Last Name*First Name

AddressCityStateZip

PhoneDate of BirthSSNDate of Acc.

*Claim File NumberInsured Name

Insured AddressInsured CityIns. StateIns. Zip

Treating Doctor Information
Dr. NameDr. AddressHosp./Group

Dr. CityDr. StateDr. ZipDr. PhoneDr. Fax

Claimant Attorney Information
NameFirm Name

AddressCity State Zip

PhoneFaxEmail

Defense Attorney Information
NameFirm NameParalegal

AddressCity State Zip

PhoneFaxEmail

Service Information
*Coverage  *Service Req. Other Service

Venue    Medical Records           TAT  

Specialtys Required:

Acupuncture    Orthopedic                 Pain ManagementNeurology              Neuropsychiatrist                                    
Chiropractic    Orthopedic Surgeon ENT                         Neuro Surgeon    Neuropsychologist    
Acu/Chiro        PM&R                         Plastic Surgeon   Internal Medicine Psychiatric  
Psychological  Dental                          TMJ                        Radiology                                          

Other Specialty

Issues to be Addressed:

 Ability to Work              Causal Relationship Degree of Disability Diagnostic Testing Diagnosis
Durable Medical Equip. Household Help        Massage Therapy    Need for Surgery    Need for Further Treatment
Need / Frequency / Duration of Treatment            Physical Therapy     Pre-existing Status
Special medical Transportation Work Restrictions 
Other Issues to be addressed

Special Instructions