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APPOINTMENT REQUEST FORM

 

So that we can efficiently process your request, please complete the following...

If you would prefer to print out a blank form and then fill it out to fax, please click here.

Use the "Tab" button to jump from field to field.  Note that hitting "Enter" will submit the form.

Exam Type
IME / FCE IME Only FCE Only
Addendum Records Review Utilization Review
Fitness for Duty Ergonomic Evaluation Job Site Analysis
Deposition    

 

Case Type
Workers' Compensation Personal Injury Long Term Disability

 

Patient Information  
First Name
Last Name
Middle Initial
Gender
Social Security #
Date of Birth //
Home Address
City
State
Zip
Home Phone
Date of Injury
Claim/File #
Type of Injury/Diagnosis
Location Requested
When do you need this IME by?
Does the patient have an attorney?
Name of Attorney
Attorney Phone
Attorney Address
 
Would you like a confirmation call to the examinee 1  business day prior to the scheduled IME?
Would you like a confirmation letter and directions to the above examinee?
Would you like a map of IME location sent with initial confirmation?
Background Information (Optional)

 

 

 

Workers' Compensation ONLY  
Employer
Title/Occupation of Injured
Date Hired
Does the IME Physician have permission to perform functional testing (FCE) if needed?

 

 

 

Referred/Submitted By *please note this will be the contact we respond back to
First Name
Last Name
Company
Address
 
City
State
Zip
Work Phone
Extension
Fax
Email

 

Please send invoice to...
First Name
Last Name
Company
Address
 
City
State
Zip
Work Phone
Extension
Fax
Email

 

 

 

 

 
 

Contact Us  |  Schedule an Appointment Online
 

The Assessment Centers

General Scheduling 1-888-676-3212

Fax (502) 568-6867

drbest@theassessmentcenters.com

 

Springs Office Building, Suite 210

950 Breckenridge Ln

Louisville, KY  40207

Phone (502) 587-0023

1019 Majestic Drive, Ste 340

Lexington, KY 40513