Independent Medical Examination (IME):

IME's are a valuable tool by which insurance companies can secure an impartial second medical opinion.

Key elements to a JBA IME include:

• Diagnosis
• Work Capability
• Causal Relationships
• Maximum Medical Improvement
• Appropriateness of Care
• Medical Recommendation
• Percentage Impairment Rating, if requested

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IME Request Form :

As an option, you may fill out one form for multiple claimants. On the bottom of the form in the specific questions to be answered by the examining physician section, enter the names of any additional claimants, along with their dates of birth and addresses, if different from the insured. If there is attorney representation, please advise if all claimants are represented by the same attorney.

Date
Adjuster Email	* Required field
Company	* Select from Dropdown Box
Adjuster
Phone Number	Extension
Fax Number
Claim Number
Date of Loss
Insured First Name
Insured Last Name
Claimant First Name
Claimant Last Name
Birthday
Social Security Num (Optional)

Please schedule a Physical Examination for:
Title	Mr Ms Mrs
First Name
Last Name
Address
Address 2
City
State	Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland & Labrador North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Yukon Territories
Zip Code
Phone W/ Area Code
Preferred Date for Physical Examination

Attorney Information:
Attorney First Name
Attorney Last Name
Address
Address 2
City
State	Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland & Labrador North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Yukon Territories
Zip Code
Phone W/ Area Code
Law Firm Name
Type of Specialty

Type of Examination:
Chiropractic	Orthopedic	Neurological
Dental	Psychiatric	Plastic Surgery
PMR	DO	ACP
DDS	M.D.	Internal Medicine
Other

Type of Case:
No Fault	Worker's Comp	Disability
PIP	UM	W/C
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: