Unimex Medical - Online IME Request Form

Claim Info

Client Contact Information

Claimant Information

Treating Physicians

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Attorneys

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Specifications

Injury Details

Attachments

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Exam Concerns

2012 Impairment Guidelines/Permanency

2018 Impairment Guidelines/SLU

ADLs

Apportionment

Causal Relationship

Claimant's Current Height and Weight

Degree of Disability

Diagnosis

Injury History

Job Description

Medications

MMI

Need for Surgery

Need for Treatment

Past Medical History

Physical Description

Physical Therapy

Prognosis

Range of Motion

Restrictions on RTW

Return to Work

Symptom Magnification

Work History

Specialists

207C

Addendum

Anesthesiology

Audiology

C-4

Cardiology

Chiropractor

Dentist

Dermatology

Ear Nose & Throat

Endocrinology

Family Practitioner

FCE

File Review

Gastroenterology

General Surgeon

Gynecology

Hearing Test

Internal Medicine

MG-2

Neurology

Neuropsychology

Neurosurgeon

Occupational Medicine

Oncology

Opthamology

Orthopedic Surgeon

Pain Management

Physical Medicine/Rehabilitation

Physical Therapy

Plastic Surgeon

Podiatry

Psychiatry

Psychology

Pulmonology

Radiology

Translator

Transportation

Urology

Vascular Surgeon

Authorized Tests

Other

X-Rays

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