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First Medical Advisory Service Request
Office Phone Number
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Fax Number
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Adjusters Name
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Email Address
*
Company Name
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Mailing Address
Patient Name
*
Sex
*
Male
Female
Claim Number
*
Nurse Case Manager and Contact Info
Attorney Name and Contact Info
Physician Preference
Claim Status
Accepted
Pending
Denied
Work Status
No Work
Light Work
Regular Work
Cover Letter
Yes
No
Specialty Preference
Ortho
PSyD
DPM
PMSE
DDS
Neuro
Pain Management
Other
If Other Specialty Preference
Interpreter
*
Yes
No
Language
Type of Claim
Workers Compensation
Disability
PIP
Auto LIA
Other
If Other Type of Claim
Type of Service
IME
Group
QME
Peer-Medical RR
Other
If Other Type of Service
Comments
General Cover Letter Questions
What are the patient's diagnosis and-or diagnoses?
Is the diagnosis causally related to the current injury or accident? Please discuss the etiology for each diagnosis and/or diagnoses?
Is there a history of prior injuries or pre-existing conditions that are impacting the current injury and its treatment thereof? If so, please explain.
Is the current treatment necessary as a result of the current injury or accident?
Can the patient return to work with or without restrictions? If work is restricted, please indicate specific restrictions and duration? Are any current work restrictions anticipated to be permanent?
Has the patient reached a permanent and stationary status? If not, please outline your recommended treatment plan (including type, frequency, duration of treatment, and anticipated date of maximum medical improvement).
Is there objective medical evidence of a permanent impairment? If so, please explain the basis for impairment and rate the percentage of impairment in accordance with the AMA Guidelines?
If stationary, please advise if supportive care is warranted and provide specific recommendations and duration.
Is this patient a surgical candidate? If so, please specify.
If this is a Petition to Reopen, please advise if there are any new, additional, or previously undiscovered medical condition(s) related to the injury that was not present at the time the case was closed. if so, please explain how the industrial injury caused this condition or diagnosis.
Do you have any additional thoughts pertinent to this injury or accident after reviewing the records/performing the examination.
If answered yes to any selections in the previous section, explain here.
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