Insured/Defendant:
Type of Case : Tort BI LTD DIS COMP No-Fault
Plaintiff prev. examined by us? (date)
Testing to Date:
Prior or Subsequent Conditions/Injuries: Treating Physician: Medical Specialty:
Physician is pre-authorized to perform x-rays or other testing in conjunction with this exam? yes no specify:
Issues to be Addressed: Causal Relation Return to Work/ADL Schedule Loss Eval. (Comp.) Degree of Disability Permanence Apportionment (Comp.) Need for Treatment/Testing Need for Surgery M&S Issues (Comp.) Specific Issues to Address and Instructions:
Client Law Firm/Insurance Co: Address: (street) (city, state, zip) Contact : (Requested by:) Phone: Attorney : Phone :
Billing Address if Different: Address: (street) (city, state, zip) Contact : Phone:
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