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Today's Date
MM slash DD slash YYYY
CONTACT INFORMATION
How can we get in touch with you if we have any questions?
Your Name*
Company
Email*
Phone*
Mailing Address
Fax Number
SERVICE REQUEST (CHECK ALL THAT APPLY)
Service Request*
- IME
- Addendum
- Functional Capacity Evaluation
- Record Review
- Other (please enter)
Enter Description
TYPE OF CLAIM
Type of Claim
- New York State Workers' Compensation
- Workers' Compensation (Non-NY)
- Fit for Duty
- No Fault
- Liability
- Occupational Accident
- Other (please enter)
Enter Description
State Jurisdiction*
For NYSWC: Will you be granting eCase access?*
- Yes
- No
If eCase access is granted we will retrieve medical records, demographics, parties of interest from the board file. All we need from you are the injury sites and issues to be addressed! If you will not be granting eCase access, please provide as much detail as possible and forward medical records when available.
NYS WCB #
NYS WCB #*
SPECIALTY REQUESTED
Specialty
- Orthopedic Surgeon
- Acupuncturist
- Anesthesiologist (PM)
- Cardiologist
- Chiropractor
- Dentist
- Hand Surgeon
- Internist
- Neurologist
- Neurosurgeon
- NeuroPsychologist
- Opthamologist (Eye)
- Otolaryngology (ENT)
- Physiatrist (PM&R)
- Podiatrist (Foot)
- Psychologist (PhD)
- Psychiatrist
- Pulmonologist
- Plastic Surgeon
- Surgeon (General)
- Other (Note Below)
Hidden
Choose Specialty
State Jurisdiction*
CLAIMANT DEMOGRAPHICS
Our office will access the claim demographics on eCase. If we have any questions we will reach out to you.
Claimant*

Full Name
Date of Birth*
Month
Day
Year
CLAIMANT & CLAIM DEMOGRAPHICS
Please provide claimant & claim demographics. Our office will reach out to you with any questions.
Claimant*

Full Name
Date of Birth*
Month
Day
Year
Address*

Street Address
Phone
S.S. # (last 4 digits)
Primary Language
Date of Accident*
Month
Day
Year
Claim #*
Carrier*

Include Address
TPA

Include Address
Insured/ Employer

Include Address
PARTIES OF INTEREST
Claimant's Attorney

please enter N/A if claimant is not represented
Treating Physicians
Other Parties of Interest
ISSUES TO BE ADDRESSED (CHECK ALL THAT APPLY)
Accepted Sites*

Specify right or left
Alleged Sites

Specify right or left
Issues to be addressed
- Select All
- Detailed Past History
- Detailed Accident History
- Detailed Treatment History
- Detailed Work History
- Casual Relation
- Diagnosis
- Prognosis
- Subjective/Objective
- Work Status
- Return to Work
- Degree of Disability
- Work Restrictions
- EPC Form
- Staus Quo Ante
- MMI
- SLU/ Permanency
- Need for Treatment
- Reasonable, Necessary & Related
- Diagnostic Testing
- Surgery
- Durable Medical Equip
- Pharmaceuticals
- NAP MTG
- PAR Review
- Apportionment
- Deadline (note below)
- Other (note below)
Deadline
Other Issues to Address
Hidden
- Detailed Accident History
Hidden
- Detailed Treatment History
Hidden
Hidden
- Detailed Work History
Hidden
Hidden
- Casual Relation
Hidden
Hidden
- Diagnosis
Hidden
Hidden
- Prognosis
Hidden
Hidden
- Subjective/Objective
Hidden
Hidden
- Work Status
Hidden
Hidden
- Return to Work
Hidden
Hidden
- Degree of Disability
Hidden
Hidden
- Work Restrictions
Hidden
Hidden
- EPC Form
Hidden
Hidden
- Staus Quo Ante
Hidden
Hidden
- MMI
Hidden
Hidden
- SLU/ Permanency
Hidden
Hidden
- Need for Treatment
Hidden
Hidden
- Reasonable, Necessary & Related
Hidden
Hidden
- Diagnostic Testing
Hidden
Hidden
- Surgery
Hidden
Hidden
- Durable Medical Equip
Hidden
Hidden
- Pharmaceuticals
Hidden
Hidden
- NAP MTG
Hidden
Hidden
- C-4 Auth
Hidden
Hidden
- MG-2
Hidden
Hidden
- Apportionment
Hidden
Hidden
- Deadline
Hidden
Hidden
- Send Carrier Questionnaire With IME-5
Hidden
Hidden
- Other
Hidden
SUMMARY OF CLAIM
COMMENTS/ OTHER
Comments
This field is for validation purposes and should be left unchanged.

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