Professional Medical Copies, Inc

Professional Medical Copies, Inc.

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Injured party:______Date of Injury: ______

Ins. Co.: ______Claim number:______

Type of Claim:

5 Med Pay 5 P.I.P. 5 Liability 5 Disability 5 Work Comp 5 Other

Prepare file for:

______IME (*see IME section below)

______Internal use or Litigation

______Nurse Review 5 Chronology 5 Narrative summary

______Physician Paper (Peer) Review

______Other:______

*If you want our staff to coordinate the IME please fill out the following:

Claimant Address: ______Phone:______

City: ______Zip:______Wk Phone: ______

Date of Birth: ______SSN: ______

Claimant’s Attorney: ______Firm:______

Address: ______City:______Zip:______

Phone: ______Fax: ______

Provider(s) Under Review: ______Specialty: ______

Address: ______City:______Zip:______

Phone: ______Fax: ______

Please list additional providers under review on the back.

**Records of all providers for all dates of service will be included unless otherwise specified

Selected Examiner (if already selected): ______

5 Send records to examiner 5 Provide additional copy(ies) to CR and/or other

Special instructions or concerns with this case: ______

Claim Representative:______Date:______

Phone: ______Fax: ______

E-Mail: @

**PLEASE REMEMBER TO ATTACH ANY QUESTIONS TO BE INCLUDED WITH THE FILE**

6970 South Holly Circle t Suite 103 t Centennial, CO 80112

Phone (303) 850-9594 t Fax (303) 850-9598