*** This form is for INJURED EMPLOYEE use only. IMO Med-Select Network® Claims Only. ***

"*" indicates required fields

Were you contacted regarding your work-related injury and was the role of the network explained by the IMO network?*
On a scale of 1 to 5 where 1 is minimal time and 5 is too much time, how long did it take between scheduling an appointment with a network treating doctor and actually seeing the doctor?*
On a scale of 1 to 5 where 1 is minimal amount of time and 5 is too much time, how long was your wait time from arriving at the doctor’s office and being taken back to the exam room?*
Your treating doctor for your work-related injury or illness (check all that apply):*
Are you currently employed and working?*
Has your current treating doctor (please select one):*
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