Request an IME/Impairment Rating

What is your appointment for?*

IME/Impairment Rating Appointment Request:

IME Requested By:

First Last

Requestors Email

Company Name:

Address

Street Address Address Line 2 City State ZIP / Postal Code

Phone

Fax

Impairment Rating Requested By:

First Last

Claim Number

Date of Injury

Requestors Email

Requestor Address

Street Address Address Line 2 City State ZIP / Postal Code

Requestor Phone

Bill & Report Information

Send Bill To:

First Last

Company Name:

Address

Street Address Address Line 2 City State ZIP Code

Email

Phone

Fax

Do we need to send a 2nd report?

Yes
No

Send Bill To:

First Last

Company Name:

Address

Street Address Address Line 2 City State ZIP / Postal Code

Email

Phone

Fax

Do we need to send a 3rd report?

Yes
No

Send Bill To:

First Last

Company Name:

Address

Street Address Address Line 2 City State ZIP / Postal Code

Email

Phone

Fax

Appointment Information:

Appointment Location

Spine Consultants, LLC - 8816 Dempster St. | Niles, IL 60714
Spine Consultants, LLC - 2514 Village Green Place | Champaign, IL 61822
Spine Consultants LLC- 3180 Agency Street | Suite 102 Burlington, IA 52601

Appointment Type:

IME
Impairment Rating
IME + Impairment Rating

Preferred Time-Frame:

Body Parts To Be Examined

Cervical
Thoracic
Lumbar
Other

If Other, Please Specify:

Authorized To take X-Rays?:

Yes
No
Approval Needed

* X-Rays are only available at the Champaign location

Patient Information:

Patient Name:*

First Middle Last

Date of Birth:*

Gender*

Phone

Cell Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Patient Speaks English:*

Yes
No/Unknown

Additional Notes:

Claim Information

Claim Type

If Other, Please Describe:

List Claims

Claim # |

Date Of Injury/Incident |

Court Case # |

Court Case Name |

Do You Have Additional Incidents?

Yes
No

Claim # |

Date Of Injury/Incident |

Court Case # |

Court Case Name |

Do You Have Additional Incidents?

Yes
No

Claim # |

Date Of Injury/Incident |

Court Case # |

Court Case Name |

Employment Information:

Employer Name

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Complete IME/Impairment Rating Request

I understand that pre-payment for all IME/Impairment Rating Appointments must be received 4 business days before scheduled appointment.

Yes

Attorney Information

If Applicable. Please fill out the information as best to your knowledge as possible.

My Appointment is for:

Case Number

Case Name

Scheduled By

Plaintiff Attorney
Defense Attorney

Attorney Name

Firm Name

Attorney Contact

Firm Address

Firm Telephone

Firm Fax Number

Opposing Attorney

Plaintiff Attorney
Defense Attorney

Attorney Name

Firm Name

Attorney Contact

Firm Address

Firm Telephone

Firm Fax Number

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