Type of Evaluation
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
Ohio BWC Location
BWC Claim Number
Client Claim Number
Date of Injury - m/d/yyyy
Reason For Exam
Diagnosis Maximum Medical Improvement Treatment Recommendations Necessity of Treatment Allowance of Claim Request for Additional Allowance Impairment Rating Disability Status Restrictions & Limitations
Allowed Condition(s)
Alleged Condition(s)
Request For Additional Allowances
Trial Date - m/d/yyyy
Supportive Services
Foreign Language Translation Transportation Mileage Reimbursement Cents/Mile
Employer
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
