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HOME CASE MANAGEMENT DECISION POINT REVIEW PRE-CERTIFICATION NETWORK ACCESS INDEPENDENT MEDICAL EXAMINATIONS BILL REVIEW & FEE SCHEDULING CONTACT US EMPLOYMENT OPPORTUNITIES FIRST MANAGED CARE OPTION	Independent Medical Exam Referral Form REPRESENTATIVE: Mr. Mrs. Ms. Company: Address: City:   State:   Zip: Phone: Fax: Email: CLAIMANT: Address: City:   State:   Zip: Phone: File/Policy #: Firm Name: Contact Attorney: Address: City:   State:   Zip: Phone: EMPLOYER: Phone: DOL: / / DOB: / / INSURED: Treating Physician: Address: City:   State:   Zip: Phone: Insurance Type: PIP   WC   BI   LTD   A&H PURPOSE OF REQUEST Examination Only   Peer Review   Peer Review And Examination   Reform Exam   # of Reschedules    Film Review   FCE   PRO   TYPE OF EXAM Chiropractic   Orthopedic   Neurology   Physical Medicine   Internal Medicine   Psychiatry   Psychology   Dental   TMJ   Other: ITEMS WHICH NEED TO BE ADDRESSED Need For Treatment   Need For Physical Therapy   Address MMI   Ability To Work   Causal Relationship   Degree Of Impairment   Medical Necessity Of:    Other: Permanency   Please complete the following section for Audit, Disability Case Management, Pre-certification or Cost Projection Referrals only: AUDIT: (Physician/Hospital) Date of Bill   Amount of Bill MEDICAL CASE MANAGEMENT    VOCATIONAL MANAGEMENT COST PROJECTION    PRE-CERTIFICATION Special Instructions    119 Littleton Road Parsippany, NJ 07054 Tel: (973) 257-5200 Fax: (973) 257-5315
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