Submit an Ancillary Service Referral - Injury Management Organization

Online Referral Instructions and Claim Issues
Online Referral Instructions*
- Maximum Medical Improvement (MMI)
- Impairment Rating
- Extent of Injury
- Disability/Direct Result
- Return-To-Work
- Return to Work for Supplemental Income Benefits (SIBS)
- Other
Peer Review Turn Around Time*
- Regular (5 - 7 Business Days)
- Rush (3 - 5 Business Days Unless Adjuster Requests Earlier)
If needed earlier than 3 - 5 Business Days, please provide date below
Claim Issues to Address*
DD Coordination - Additional Questions*
Please provide the specific reason(s) for the requested examination. The reason(s) must indicate how the examination will resolve a dispute or assist in the progression of the claim.
DD Coordination - Additional Questions cont'd*
If a previous designated doctor examination has occurred for this claim, explain any change of medical condition since that examination
DD Coordination - Additional Questions cont'd*
If approval of this request would result in TDI-DWC scheduling an examination within 60 days of a previous designation doctor examination, provide good cause as to why it is necessary to schedule this examination within 60 days.
DD Coordination - Additional Questions cont'd*
List all injuries determined to be compensable by TDI-DWC or accepted as compensable by the insurance carrier.

Record Delivery & Attachments
Deliver records by:*
- I will attach all records to this form below - Please name files based on the patient's last name
- I will fax all records to the IMO Ancillary Dept. at 877-425-5353
- I would like an IMO representative to pick-up
Important Disclaimers

IMO has been retained to provide the above services and therefore has access to medical records on this case. The details contained in this form are privileged and confidential information intended for the sole use of the individual or entity named above.
Acknowledgement of terms*
- I agree
Form Suggestions/Feedback/Comments
We want to know how we can better serve you through our online submission process! Please provide suggestions/feedback in this box or email info@injurymanagement.com.