Exam Peer Review Film Review Addendum
Claimant Name
 File #
Claimant Address
City
 State
 Zip Code
 Phone #
Insurance Coverage
Disability
LTD Individual
STD Group
Other:
Health/Life/Credit
Major Medical Premium Waiver
Second Medical Opinion
Other:
Carrier/ Firm
Address
City
 State
 Zip Code
File Supervisor
 Phone #
 E-mail
Claimant Attorney
 Phone #
Address
City
 State
 Zip Code
Claimant Occupation
 Date of Disability
Monthly Benefits
 Diagnosis
Treating Physicians:
Specialty  Request:
Orthopedist Chiropractor
Psychiatrist Neurologist
F.C.E. Psychologist
Obtain prescription for F.C.E. Plastic Surgeon
Provide transportation if necessary General Surgeon
Ophthalmologist E.N.T
Internal Medicine
Other:
Specific Areas of Concern:
Diagnosis/Prognosis Need for Further Treatment
Medical Necessity of Treatment Degree/Percent of Disability
Permanency Ability to Work
Work Restrictions Ability to Perform Own Occupation
Ability to Perform Any Occupation
Special Instructions:
Please Attach Attending Physician Reports, Job Description and Patient Medical Consent (if available)
Records
Attached Mailed
Faxed to 732.382.2035 Pick up on-site
 
  




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