100 Jericho Quadrangle Suite #103
Jericho, NY 11753
Telephone (516) 806-2444
Facsimile   (516) 806-2440
Email: IME@mcmcllc.com
Bold Fields Are Required                                                                                      Online Request Form
Service Request Type: IME     Peer Review     Radiology Review      Med Pay     Group Health   PIP

                                                                                                   Obtain Films Films to be sent

 
Coverage Type: No-Fault              Liability-county pending      Disability       WorkersCompensation
                                      
Initial IME              Re-evaluation-last performed by Date of Exam
                                                                
      Check if you are a Defense firm: 
Carrier Date of Request
Representative Policy #
Email Address Claim #
Address Insured
City/State/Zip Date of Injury
Telephone/Ext WCB No.
 
Is Claiment Represented?
Yes No
Claimant Information Claimant's Attorney Information
Name Name
Address Address
City/State/Zip City/State/Zip
Home Telephone Telephone #
Work Telephone Fax #
SSN Jurisdiction(ST)
Date of Birth County(Venue)
 
Specialists Required:
Acupuncturist General Surgeon Neuro-Surgeon Plastic Surgeon ENT
Cardiologist Internist Opthalmologist Psychologist Podiatrist
Chiropractor Neurologist Orthopedist Psychiatrist  
Dentist Neuro-Psych PM&R Pulmonary  
Other (specialty)
Specialist Requested
 
Issues to be Addressed    
Causal Relationship Need for treatment Capacity to Work
Degree of Disability Frequency/Duration of Treatment Light Duty Restrictions
Necessity of Surgery Necessity of Additional Testing M & S Issues
Prognosis Need for Medical Durable Goods Apportionment
Need for Diagnostic Testing Schedule Loss of Use Maximum Medical Improvement
Need for Transportation Permanency Target Return to Work
 

Injuries
Treating Physician
Additonal CC1
Additonal CC2
Additonal CC3
 

Additional Issues/Instructions: (For Peer Reviews, please provide the date of service and cost associated with the procedure treatment, and/or testing specifically under review)

 
Are there currently any medicals to review? ( Yes No)
 
     
  Send form to MCMC  Print This Page