Service Requested
Physician Specialty
If other, please specify
Requestor Information
Name *
Company *
Address
City / State / Zip
Phone *
Fax
Email Address
Claimant Information
Name (First / Middle / Last) *
DOB - m/d/yyyy
SSN
City / State / Zip *
Phone
Claim Information
Claim/Control Number
Date of Injury - m/d/yyyy
Allegation
Attending Physician(s)
Employer
Issues To Be Addressed
Please address the current diagnosis, history of injuries, and any preexisting conditions that one found to exist.
Is there a causal relationship between the accident and/or injury described and the claimant's current pathology?
Based on your examination, has the patient reached a level of Maximum Medical Improvement?
Does the patient have any work restrictions as a result of the accident and/or injury suffered? If so, please specify restrictions and duration of restricted work.
Is ongoing treatment (including diagnostics) reasonable and medically necessary for the accident and/or injuries described? If so, please outline frequency, duration and type of treatment recommended.
Supportive Services
Foreign Language Translation Transportation Verbal Request
Attorney Information
Defense Attorney
Plaintiff Attorney
Will you be forwarding specific questions for the provider to address?
Should MLS send a confirmation letter to the claimant regarding this appointment?
Additional Comments
Cover Letter
Other Files
Attachment 1
Attachment 2
Attachment 3
Attachment 4
Attachment 5
