FO&L Required Medical Exam Service Request

Your Information

Date of Request:

7/26/2017 3:27:56 AM

Your Name: (required)
First: Last: 
Your Email Address: (required)   
Your Phone Number:

Adjuster Information

Adjuster Name:
First: Last: 
Adjuster Phone:
Adjuster Fax:

Claimant Information

Claimant Name: (required)
First: Last: 
Claim Number: (required)  

Carrier & TPA Information

Carrier Name:
TPA Name:

Network Claim


 

Requested Actions and Documentation


Request DR. from Texas.















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Questions

PLEASE NOTE: Questions regarding medical treatment may not be asked of a post-DD RME and may not be asked in cases where the claimant is in a network. Similarly, questions directed to the post-DD RME must be with respect to issues for which the DD was appointed. FOL will review the questions and ensure that only questions allowed by the statute and rules are presented to the RME.

Medical Treatment (Medical Treatment RME)









Extent of Injury (Post-Designated Doctor RME)













Disability (Post-Designated Doctor RME)







Maximum Medical Improvement/Impairment Rating (Post-Designated Doctor RME)







Other

Please note the caveat bolded above before submitting any additional questions.

Flahive, Ogden & Latson
Phone No: 512-435-2299
P.O. Box 201329, Austin, TX 78720
Fax No: 512-241-3332
Email: rme@fol.com