Diagnostic Test Review

We will offer you a quality physician to review X-rays, CT scans and MRI films to offer a 2nd opinion on the diagnostic test given by the treating physician.

Diagnostic Review Form :

Date
Adjuster Email	* Required field
Company	* Select from Dropdown Box
Adjuster
Phone Number	Extension
Fax Number
Claim Number
Date of Loss
Insured
Claimant

Attorney Information:
Attorney Name
Address
Address 2
City
State
Zip Code
Phone W/ Area Code
Type of Specialty

Type of Examination:
Chiropractic	Orthopedic	Neurological
Dental	Psychiatric	Plastic Surgery
Internal Medicine	Other

Type of Case:
No Fault	Worker's Comp	Disability
BI	Other

Treating Physician:
Name
Address
Address 2
City
State
Zip Code
Phone W/ Area Code
Current Diagnostic

Documents:

Specific questions to be answered by the examining physician: