IME Request Form

Fax: (651) 304-1444

Monday – Friday 7:30 AM – 5PM CST

Apex Expert Group

New Website

INDEPENDANT MEDICAL EVALUATION (IME) FORM

Client Name*
First Last
Company Name
Email*
Type Of Claim*
State Of Jurisdiction*
Service*
Specialty
Scheduling Time Frame*
Attorney Represented
Petitioner Attorney Name
First Last
Petitioner Attorney Phone
Comments
Claim Questions To Address
- Causation
- Nature and extent of injury
- Treatment Appropriateness
- Treatment Recommendation
- Return to work status / Restriction Clarification
- Maximum Medical Improvement (MMI)
- Impairment Rating
Body Parts Injured
- Head - Closed Head Injury
- Cervical Spine (Surgical)
- Cervical Spine (Non-Surgical)
- Upper Extremity - Multiple
- Right Shoulder (Surgical)
- Right Shoulder (Non-Surgical)
- Left Shoulder (Surgical)
- Left Shoulder (Non-Surgical)
- Elbow
- Wrist
- Right Hand (Surgical)
- Right Hand (Non-Surgical)
- Left Hand (Surgical)
- Left Hand (Non-Surgical)
- Thoracic Spine
- Lumbar Spine Injury (Surgical)
- Lumbar Spine Injury (Non-Surgical)
- Hip
- Left Knee (Surgical)
- Left Knee (Non-Surgical)
- Right Knee (Surgical)
- Right Knee (Non-Surgical)
- Pyschological
- Neurological
- Cardio Pulmonary
- Rheumatology Arthritis
- Gastro Intestinal
- General Medical
- Ear/Nose/Throat
- Eye/Vision
- Dental
- Vascular
- Ankle/Foot
- Other
Current Diagnosis
Examinee Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Examinee Email
Claim Number
Date Of Injury
Date Format: MM slash DD slash YYYY
Date Of Birth
Date Format: MM slash DD slash YYYY
Gender
Additional Comments

Corporate Address

Apex Expert Group, LLC
600 85th Lane NW #5
Minneapolis, MN 55433
Phone: (952) 546-1632
Fax (651) 304-1444

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