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Submit an Ancillary Service Referral

Submit an Ancillary Service ReferralMedingenuityAdmin2020-04-27T16:12:03+00:00

Step 1 of 8 - Patient Information

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  • Service(s) Requested

  • Patient Information

  • Injury Details

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Attorney Information

  • Treating Provider

  • Online Referral Instructions and Claim Issues

  • 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.
  • If a previous designated doctor examination has occurred for this claim, explain any change of medical condition since that examination
  • 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.
  • List all injuries determined to be compensable by TDI-DWC or accepted as compensable by the insurance carrier.
  • Referred By Information

  • MM slash DD slash YYYY
  • Record Delivery & Attachments

  • 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.

  • 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.
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