JBA Medical

Date

Adjuster Email

Company

Adjuster

Phone Number

Fax Number

Claim Number

Policy Number

Date of Loss

Insured First Name

Claimant/Patient First Name

Insured Last Name

Claimant/Patient Last Name

Claimant/Patient Address

Claimant/Patient Date of Birth

City

State

Zip Code

Phone W/ Area Code

Preferred Date for IME

Social Security Num (Optional)

Transportation Needed

Translator Needed

Language

Attorney First Name

Attorney Last Name

Law Firm Name

Address

Address 2

City

State

Zip Code

Phone W/ Area Code

Fax Number

Other

Name

Address

Address 2

City

State

Zip Code

Phone W/ Area Code

Current Diagnostic

"EXCEEDING THE STANDARDS"

Key elements to a JBA IME include:

Ime Referral Form :

Attorney Information:

Type of Review:

Type of Case:

Treating Physician:

Documents:

Specific questions to be answered by the examining physician:

Please include additional Claimants needing exam in this section.