American Medical Enterprises
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American Medical Enterprises

TYPE OF REFERRAL:

American Medical Enterprises
American Medical Enterprises
W/CN/FLiabilityPeer ReviewOther
American Medical Enterprises
Comment:
American Medical Enterprises

CLIENT INFORMATION:

American Medical Enterprises
American Medical Enterprises
Date of Request:
Re-Exam:
YesNo
Company Name:
Adjusters Name:
Telephone:
Address:
E-Mail Address:
American Medical Enterprises

CLAIMANT INFORMATION:

American Medical Enterprises
American Medical Enterprises
Claimants Name:
Telephone:
Address:
Employer:
Nature of Injury:
Date of Injury:
Claim #:
WCB #:
Date of Birth:
Social Security:
American Medical Enterprises

ATTENDING PHYSICIAN:

ATTORNEY:

American Medical Enterprises
American Medical Enterprises
Notification Letter to Examinee:
YesNo
Attorney:
Telephone:
Address:
Attending:
Telephone:
Address:
 
American Medical Enterprises

TYPE OF EXAM:

American Medical Enterprises
American Medical Enterprises
OrthopedicNeurologicNeuro SurgeonChiropracticPM&R
Radiology ReviewOtherRe-Exam?
DiagnosisPrognosis
Past Medical HistoryHas Pre-Accident Status Been Achieved?
Casual Relationship To InjuryMedical End-Result Achieved?
Casual Relationship To Present SymptomsCan Claimant Return To Work?
Permanency RatingApportionment?
Is Treatment Reasonable And Necessary?What Are The Claimant's Capabilities?
Is Further Treatment Needed?Degree Of Disability
Does The Claimant Have Restrictions?M&S Statement (15-8)
Medical Records Need To Be CopiedMedical Records Will Be Mailed To AME
No Show - Reschedule ImmediatelyNo Show - Contact Adjuster Before Rescheduling
American Medical Enterprises
Comment:
 
American Meical Enterprises