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IME-Peer Review Required Documentation
                          CHECKLIST


Please complete this checklist and attach it to the top your submission package


via fax (203-546-8925) or scan and email to: This email address is being protected from spambots. You need JavaScript enabled to view it.



Patients Name________________________________ DOB______________


Insurance Company Name:________________________________________

Insurance Company Address:_______________________________________

Insurance Company Policy #:_______________________________________


Circle Y if enclosed or N if not:

Y N - IME - Peer Review - Carrier report/denial

Y N - New
Patient's initial intake form


Y N - Initial evaluation: Dated ___________

Y N - All Re-evaluations: Dated ____________

Y N - Diagnostic reports (MRI, CT scan, X-ray digitization, EMG/NCV, etc.)

Y N - All treating doctors/therapists reports (orthopedist, neurologist, physiatrist, other) 

Y N - Patient's own Functional Loss ( personal – social – work) statement(s)

Y N - Executed (signed) HIPAA Chain of Trust Agreement(ONLY ONCE)

Y N - Daily SOAP notes, Re-evaluation
s, Oswestry or similar forms


Print clearly

Dr.'s (name on report)Name: ______________________________________________________

Address:_______________________________________________________________________

Telephone:________________________ Email:_______________________________________


Your opinion on why this case should be rebutted and overturned about this case: (PRINT legibly)









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