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(952) 546-1632

Fax: (651) 304-1444

Monday – Friday 7:30 AM – 5PM CST

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Apex Expert Group

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INDEPENDENT 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 City State ZIP Code
Phone
Examinee Email
Claim Number
Date Of Injury
MM slash DD slash YYYY
Date Of Birth
MM slash DD slash YYYY
Gender
Additional Comments

Δ

Corporate Addresses

Apex Expert Group, LLC
600 85th Lane NW #5
Minneapolis, MN 55433

4000 W. Montrose Ave #2208
Chicago IL. 60641.

106 West Osborn Rd #1002
Phoenix AZ 85013

Phone: (952) 546-1632
Fax (651) 304-1444

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