Service Requested
Physician Specialty
If other, please specify
Type of Evaluation
Requestor Information
Name *
Company *
Address
City / State / Zip
Phone *
Fax
Email Address
Insured Information
Name (First / Middle / Last) *
DOB - m/d/yyyy
SSN
City / State / Zip *
Phone
Claim Information
Claim Number
Diagnosis
Date of Disability - m/d/yyyy
Attending Physician(s)
Employer
Issues To Be Addressed
What is the claimant's current diagnosis?
Provide a description of the claimant's impairments, if any (i.e. deficit in motion, strength deficit, pain, etc.). If impairment exists, please list specific physical restrictions.
Please outline the current treatment plan and comment if treatment has been consistent with professional standards of care?
What are the claimant's treatment recommendations?
Please describe the physical observations of the claimant and comment on whether they were consistent with clinical exam findings.
Can this claimant return to their own occupation?
Can this claimant return to any occupation? (Physical demand levels will be included for physician review).
Other Issues to be Addressed
Supportive Services
Foreign Language Translation Transportation
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
