INTEGRATED RISK SERVICES INC.

P.O. BOX 85 SYOSSET, NEW YORK 11791-0085 | TEL 516-682-0667 | FAX 516-682-0668

WORKERS' COMPENSATION IME REQUEST FORM

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Requestor	Company	Telephone / Fax Numbers	E-Mail Address
Your File Number Date of Injury WCB Number Claimant Information Full Name (First, Last) Address City State & Zip Telephone Number Social Security Number Current Work Status Working Working Light Duty Not Working Unknown See Special Instructions Medical Records Will E-Mail or Fax Will Mail Please Access E-Case Please Copy & Pickup See Special Instructions	Employer Claimant's Attorney Claimant's Physician   Medical Specialty Orthopedic Surgeon Chiropractor Neurologist Hand Surgeon Cardiologist Dermatologist Gastroenterologist General Surgeon Internist Neurosurgeon Ophthalmologist Oral Surgeon Otolaryngologist Plastic Surgeon Psychiatrist Pulmonist Radiologist Urologist Vascular Surgeon Other   Examination Issues DIAGNOSIS CAUSAL RELATIONSHIP DEGREE OF DISABILITY NEED FOR TREATMENT RETURN TO WORK NEED FOR SURGERY SCHEDULE LOSS CLASSIFICATION M & S EVALUATION APPORTIONMENT	Employer's Full Address Attorney's Full Address Claimant's Physician's Full Address Established Injury Sites (NONE IF NONE) Special Instructions

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