Submit an Ancillary Service Referral

1

Service(s) Requested

Service(s) Requested*

If other, please provide below

Type of Peer Review

Type of RME*

RME for Appropriateness of Treatment
Post DD RME

2

Claim Profile

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*

Date of Injury (D.O.I)*

D.O.B.*

Mechanism of Injury*

Date of Statutory MMI

Diagnosis, Medical Information, Test Results*

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 Phone*

Treating Provider Fax

Treating Provider Email

Treating Provider Address

Street Address Address Line 2 City State ZIP Code

3

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.

4

Referred By Information

Contact Name*

First Last

Company Name*

Location (city)

Contact Phone Number & Extension*

Contact Fax

Contact Email*

Today's Date*

5

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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Important Disclaimers

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