CIRA MEDICAL SERVICES

Confidential Referral Form – Alberta Accident Benefits

INSURER Information

Company
Street Address / Claim Number
City / Province / Postal Code
Adjuster
Name / Date of Loss
(mm/dd/yy)
Phone/Fax / Email Address

CLAIMANT information

First Name / Last Name
Sex / Male / Female / Date of Birth
(mm/dd/yyyy)
Street Address / Suite/Apt#
City / Province / Postal Code
Phone / Email
Diagnosis, Description of Injury, Special Requests
LEGAL REPRESENTATION
Law Firm
First Name / Last Name
Phone / Fax
Address
Email
ASSESSMENT TYPE
Exam Type: / IME / MSE (GP only) / Certified Examination (CE)
Job Site Analysis / FAE / In Home Assessment
Labour Market Survey / Psychovocational / Transferable Skills Analysis / Vocational
Specialty Type (for IME & CE only):
Dentistry (IDE) / Orthopedic Surgery / Physiatry / General Practitioner / Neurology
Internal Medicine / Neurosurgery / Occupational Medicine / Psychiatry / Psychology
Neuropsychology / Otolaryngology (ENT) / Pediatrics / Plastic Surgery / General Surgery
Respirology / Rheumatology / Oral Surgery / Gastroenterology / Ophthalmology
Other (specify type)
Diagnostic Imaging
Bone Scan / CT Scan / MRI / X-ray / Other

additional services to be arranged by Cira

Transportation
Ground
Air / Yes / No / From / To
Translation
Required / Yes / No / Language:
Accommodation Required / Yes / No / Instructions:
Please note that transportation and translation services will be arranged by Cira at no additional administrative cost. An invoice from the transportation and/or translation company will be sent directly to the referral source for payment.
Would you likeCira to initiate direct contact with theexaminee strictly to communicate the appointment details? / Yes / No / If so, how? / Phone / Letter / Both

referral questions:

If you prefer to attach your own letter of instruction to the medical file please check this box:
MSE / IME Referral Questions
Within the scope of your medical discipline, what is examinee’s primary & secondary diagnosis?
Within the scope of your medical discipline, what is examinee’s prognosis? Has maximum medical recovery been reached?
Are the reported symptoms consistent with the diagnosis?
Is the claimant partially or totally and wholly disabled?
If disabled, what activities are restricted and why? What is the anticipated duration of the restrictions?
Is the claimant able to return to work on a part time or graduated basis?
If the claimant is wholly and totally disabled, what is the estimated date of return to work?
Are there any obstacles preventing a return to work?
Please comment on the past and current treatment, including nature, frequency and duration.
What are your recommendations for treatment? Specifically describe the nature, frequency and duration of the prescribed treatment?
Causation Questions – can be addressed only by an IME, not by an MSE
Is the injury a result of the MVA? Or is the injury a consequence of a pre-existing condition?
Is there a pre-existing condition impacting the return to pre-accident function? If yes, please elaborate.
Certified Examination Questions (please only check if you have requested a CE)
Please provide a diagnosis
Was the claimant treated within the Diagnostic and Treatment protocols?
Is there a “Serious Impairment”?
Is the injury sustained in the motor vehicle accident considered to be a Minor Injury or not? Please explain.
·  Is there a “Serious Impairment”?
·  Is the injury sustained in the motor vehicle accident considered to be a “Minor Injury” or not?
**Additional and/or alternative Questions can be typed on a separate document and attached to this referral form**

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Please fax back to 1-888-444-3094