LAST NAME / FIRST
TAX ID / EMAIL
SPECIALITY INFORMATION
PRIMARY / BOARD CERTIFIED
YEAR CERTIFIED / EXPIRATION DATE
SECONDAY / BOARD CERTIFIED
YEAR CERTIFIED / EXPIRATION DATE
CONTACT INFORMATION
CHECKS PAYABLE / TAX ID #
ADDRESS / CITY, STATE, ZIP
PHONE / FAX
SEND MEDICALS / ATTENTION
ADDRESS / CITY, STATE, ZIP
PHONE / FAX
OFFICE LOCATIONS
ADDRESS
CITY, STATE, ZIP / COUNTY
PHONE / FAX
ADDRESS
CITY, STATE, ZIP / COUNTY
PHONE / FAX
ADDRESS
CITY, STATE, ZIP / COUNTY
PHONE / FAX
ADDRESS
CITY, STATE, ZIP / COUNTY
PHONE / FAX
ADDRESS
CITY, STATE, ZIP / COUNTY
PHONE / FAX
EXAM / REVIEW FEES
WC IME / RECORD REVIEW
SLU IME / PEER REVIEW
DISABILITY IME / RADIOLOGY IME
LIABILITY IME / 1STNO SHOW
AUTO IME / 2NDNO SHOW
ADDENDUM / 3RDNO SHOW
DEPOSITION / TESTIMONY FEES
WC PHONE DEPO / PTC
½ DAY TESTIMONY / FULL DAY
TERMS
TERMS
LICENSE INFORMATION
STATE / ISSUED
RENEWAL / LICENSE #
STATE / ISSUED
RENEWAL / LICENSE #
MALPRACTICE INFORMATION
CARRIER / CONTACT
PHONE / FAX
POLICY # / RENEWAL DATE
CLAIM AMOUNT / AGGREGATE
FOREIGN LANGUAGES
LANGUAGE / SPEAK / READ / WRITE / FLUENT
LANGUAGE / SPEAK / READ / WRITE / FLUENT
PLEASE ANSWER ALL QUESTIONS
THE FOLLOWING IS A CONTRACTUAL AGREEMENT BETWEEN THE HEALTHCARE PROVIDER (HCP) AND READ-REPORTS, INC. THE NATURE OF THIS AGREEMENT INCLUDES ONLY NON-TREATMENT SERVICES SUCH AS INDEPENDENT MEDICAL EVALUATIONS, FILE REVIEWS AND OTHER NON-TREATMENT RELATED SERVICES. ALL INFORMATION CONTAINED IN THIS AGREEMENT AND IN ANY REFERRAL THAT IS SENT TO YOUR OFFICE, IS PRIVILEGED AND SHOULD BE HELD IN THE STRICTEST OF CONFIDENCE. ANY DISCLOSURE AND/OR DISTRIBUTION TO ANY PARTY, OTHER THAN AN AGENT DESIGNATED BY YOU TO ACT ON YOUR BEHALF, IS PROHIBITED.
YOUR REPORT TURN AROUND TIME IS CRITICAL IN MEETING THE NEEDS OF OUR CLIENTS. IF YOU ANTICIPATE YOUR REPORT BEING DELAYED, PLEASE CONTACT OUR OFFICE AT ONCE. DEPENDING UPON THE LEGAL ARENA WE ARE WORKING IN, YOUR REPORT COULD BE PRECLUDED FROM THE FILE FOR FAILAURE TO SUBMIT YOUR FINDINGS WITHIN THE SPECIFIED TIME FRAME. SHOULD YOUR REPORT BE PRECLUDED FOR REASONS ARISING OUT OF YOUR OFFICE, READ-REPORTS, INC RESERVES THE RIGHT TO WITHHOLD AND/OR DENY PAYMENT TO YOU AS A RESULT.
ANY DIRECT ATTEMPT TO CONTACT CLIENTS, CONTACTS AND/OR SOURCES OF READ-REPORTS, INC TO SECURE DIRECT REFERRAL FROM THEM IS CONSIDERED A VIOLATION OF THIS AGREEMENT, JEOPORADIZING ANY FURTHER RELATIONSHIP AND/OR REFERRAL FROM OUR OFFICE. BY SIGNING THIS AGREEMENT, YOU ACKNOWLEDGE AND AGREE THAT DISTRIBUTION OF EXAMINATION RESULTS WILL BE MADE THROUGH THE OFFICES OF READ-REPORTS, INC.
DO YOU CURRENTLY HOLD AN ACTIVE, VALID, UNRESTRICTED LICENSE TO PRACTICE MEDICINE BY YES NO
THE APPROPRIATE STATE LICENSING AGENGY?
HAS YOUR INSURANCE COMPANY EVER CANCELLED, DECLINED, REDUCED, RESTRICTED OR REFUSED YES NO
TO RENEW YOUR MALPRACTICE INSURANCE? IF YES, PLEASE ATTACH AN EXPLANATION.
HAS YOUR LICENSE TO PRACTICE MEDICINE EVER BEEN LIMITED, RESTRICTED, SUSPENDED OR YES NO
REVOKED FOR ANY REASON? IF YES, PLEASE ATTACH AN EXPLANATION.
HAVE THERE BEEN, OR ARE THERE CURRENTLY, ANY STATE LICENSING INVESTIGATIONS, CLAIMS OR YES NO
ACTIONS AGAINST YOU? IF YES, PLEASE ATTACH AN EXPLANATION.
HAVE YOU EVER BEEN DENIED PARTICIPATION OR RENEWAL OF PARTICAPATION, IN ANY WORKERS’ YES NO
COMPENSATION, AUTO INSURANCE, HOSPITAL OR MANAGED HEALTHCARE ORGANIZATIONS? IF YES,
PLEASE ATTACH AN EXPLANATION.
HAVE YOU EVER BEEN REPRIMANDED, DISCIPLINED OR SUSPENDED BY A HEALTHPLAN, MEDICARE/ YES NO
MEDICAID OR PROFESSIONAL STATE OR FEDERAL BOARD? IF YES, PLEASE ATTACH AN EXPLANATION.
ARE YOU AUTHORIZED BY YOUR STATES WCB TO PERFORM IME’S? IF YES, PROVIDE YOUR YES NO
***** AUTHORIZATION NUMBER: ______
HAVE YOU FULFILLED STATE REQUIREMENTS, WHERE APPLICABLE, TO PERFORM IME’S AND FILE YES NO
REVIEWS? IF YES,
DO YOU AGREE NOT TO DISCLOSE CONFIDENTIAL PATIENT INFORMATION OR REPORTS TO ANY YES NO
PARTY OTHER THAN READ-REPORTS, INC UNLESS SO AUTHORIZED BY READ REPORTS INC?
DO YOU AGREE TO BE IMPARTIAL, WITHOUT BIAS, TOWARDS THE CLAIMANT, REFERRAL SOURCE OR YES NO
ANY OTHER PARTY THAT HOLDS INTEREST?
ARE YOU AWARE THAT WE (YOU) ARE PROHIBTED FROM DISCUSSING AND GIVING TREATMENT YES NO
ADVICE TO THE CLAIMANT?
DO YOU AGREE TO INDEMNIFY AND HOLD READREPORTS, INC, ITSCLIENT, SOURCES ANDTHEIR YES NO
RESPECTIVE OFFICERS, DIRECTORS AND EMPLOYEES HARMLESSFROM ALL CLAIMS AND DAMAGES
ARISING DIRECTLY OR INDIRECTLY, FROM OBLIGATIONSCONCERNING YOUR PERFORMANCE OF, OR
FAILURE TO PERFORM, SERVICES AS PER THIS AGREEMENT?
DO YOU AGREE THAT X-RAYS OR ADDITIONAL DIAGNOSTIC TESTS ARE NOT AUTHORIZED AT THETIME YES NO
OF THE IME UNLESS YOU HAVE PRIOR, WRITTEN AUTHORIZATION FROM THE OFFICES OF READREPORTS?
DO YOU UNDERSTAND THAT SERVICES PERFORMED UNDER THIS AGREEMENT ARE SOLEY TO BE PERFORMED YES NO
AS AN INDEPENDENT CONTRACTOR AND NOT AS A JOINT VENTURE, EMPLOYEE OR AGENT OF READREPORTS
AND THAT ALL RULES, REGULATIONS AND OBLIGATIONS OF AN INDEPENDENT CONTRACTOR APPLY?
ARE YOU CURRENTLY IN ACTIVE PRACTICE? YES NO
HOW MANY INDEPENDENT MEDICAL EXAMINATIONS DO YOU PERFORM, ON AVERAGE, EACH WEEK? NUMBER OF EXAMS
I HAVE READ AND AGREE TO THE TERMS AND CONDITIONS ABOVE.
THE INFORMATION PROVIDED IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE.
HEALTH CARE PROVIDER
SIGNATURE OF PROVIDER
DATE SIGNED
CREDENTIALS CAN BE MAILED, FAXED OR EMAILED - BE SURE TO INCLUDE:
- READREPORTS PROVIDER APPLICATION
- A COMPLETED AND SIGNED W-9
- COPY OF YOUR CURRENT LICENSE
- COPY OF YOUR MALPRACTICE INSURANCE
- COPY OF YOUR CV
- A SAMPLE REPORT
PO BOX 588, MODENA, NY 12548
TELEPHONE: 845-255-3267
FACSIMILE: 845-255-1405
EMAIL:
WEBSITE:
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