Online Referral Form

Prizm Medical Resources, Ltd. provides comprehensive Independent Medical Evaluations (IME), Medical Record Reviews, Peer/Utilization Reviews, Diagnostic Film Reviews, Fitness for Duty Evaluations, Psychological/Neuropsychological Evaluations and Vocational Evaluations across the U.S.

Please complete all applicable fields on the form.

Referring Party:
Claimant Information:
Attorney Information:
Service Requested:

IME

Specialty

Selected Doctor

Medical Record Review

Film Review by Neuro/Radiologist

or by IME Doctor

Claim Rep in possession of films

Vocational Assessment

AMA Impairment Rating

Re-Evaluation

Other

Type of Claim:

Automobile Liability

Workers' Compensation

General Liability

STD

LTD

Other

Issues to be Addressed:

Current Diagnosis/Causal Relationship

Extent of Disability

Seriousness/Permanency

MMI

Future Treatment

Residuals

Pre-Existing

Reasonableness/Necessity

Physical Capabilities

Billing Party:
Comments/Special Instructions: