IME Appointment Request Form

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Form Type*
- IME Appointment Request
- Impairing Rating Request
- IME with IR Request
- IME Re-evaluation
- Chart Review
- Second Opinion
- Long & Short Term Disability
- FMLA
Patient Information
Name*
First Last
SSN
Birth Date*
MM slash DD slash YYYY
Current Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Is Patient English Speaking?*
- Yes
- No
Claim Number*
Injury Date*
MM slash DD slash YYYY
Injury(s)
Treating Physician Full Name
XRays must be PreAuthorized*
- Yes
Scheduling Period
Impairment Rating
- One Body Part
- Two Body Parts
- Three Body Parts
- Four or More Body Parts
- Upper Extremity
- Lower Extremity
- Spine/Pelvis
Request Provider*
- Yes
- No
If Yes, Provider Name
Special Instructions
Referral Info
Referral Name*
Send Referral Email Confirmation to*
Referral Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Referral Phone*
Payor Information
Payor Name
Send Payor Email Confirmation to*
Payor Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Payor Phone*
Payment Terms*
- Pre-Pay
- Post-Pay

Contact Us

800.910.6139

info@ppgime.com

Mon-Fri: 8:00 – 5:00 EST