In order to provide our clients with the highest quality results, we would request the following information as appropriate and applicable for all referrals. 

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INJURED WORKER/PATIENT INFORMATION
	Complete name, address & contact information
	DOB & SSN
	DOI, IW & Supervisor’s description of injury and FROI
	Occupation; Job Description with essential physical strength and postural demands and any specific job task requirements
CLAIMS ADJUSTER
	Complete name, address (billing) & contact information – fax and email address
	Claim number
	Is this evaluation for OWN occupation or ANY occupation?
	Provide any specific questions to be addressed by evaluation
CASE MANAGER
	Complete name, address (billing) & contact information – fax and email address
	Case Number
	Is this evaluation for OWN occupation or ANY occupation?
	Provide any specific questions to be addressed by evaluation
PHYSICIAN
	Complete name, office address & contact information – fax and email address
	Provide a copy of your practice patient demographics sheet & script
	ICD-9 (s)
	Relevant medical records – previous injuries, accidents, diagnostic reports, operative notes, list of medications & dosages, number of PT sessions, dates/responses to any procedures
	Initial diagnosis, physician evaluation and most recent clinic notes
	Impairment Rating Analysis – AMA 5th Edition
	Impairment Rating Analysis – AMA 6th Edition – Required for Federal employees