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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
Service(s) Requested*
If other, please provide below
Type of Peer Review
- Peer Review (Standard)
- Peer Review Addendum
- Peer Review Clarification
- Analysis Letter Only
- Letter Response / Rebuttal
- Impairment Rating (IR) Review
- Early Compensability Assessment
- MRI Re-Read
- Medication Review
- Percent of Contribution
- Cumulative Impact Review
Type of RME*
- RME for Appropriateness of Treatment
- Post DD RME
Patient Information
Patient Name*
First Last
Patient Job Title/Department*
Patient Phone*
Patient Email
Patient Address*
Street Address Address Line 2 City State ZIP Code
Claim Number*

Injury Details
Date of Injury (D.O.I)*
MM slash DD slash YYYY
D.O.B.*
MM slash DD slash YYYY
Mechanism of Injury*
Date of Statutory MMI
MM slash DD slash YYYY
Diagnosis, Medical Information, Test Results*

Attorney Information
Employer Name*
Supervisor Name
Employer Phone
Employer Fax
Employer Email
Employer Address
Street Address Address Line 2 City State ZIP Code

Attorney?*
- Yes
- No
Attorney Name
Attorney Email
Attorney Phone
Attorney Fax

Treating Provider
Treating Provider*
Treating Provider Phone*
Treating Provider Fax
Treating Provider Email
Treating Provider Address
Street Address Address Line 2 City State ZIP Code

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.

Referred By Information
Contact Name*
First Last
Company Name*
Location (city)
Contact Phone Number & Extension*
Contact Fax
Contact Email*
Today's Date*
MM slash DD slash YYYY

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.

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