Referral Checklist for 3D Motionprint® Evaluation Services

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

PDF Version

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