Medical Management Group of New York, Inc. - Appointment Request Form
 

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Company Information
 
Company Name: 
Address: 
Town/State/Zip:
Attention:  
Phone:  
FAX: 
E-Mail:
Defense Council Information
 
Defense Counsel Name:
Address:
Town / State / Zip:
Attention:
Phone:
E-Mail Address:
Do you want to send a copy of the report to your defense counsel ?   Yes No
 
 

Claimant Information
 
Claimant Name:
Address:
Town/State/Zip:
Phone:
DOB (mm/dd/yy)
Soc. Sec. Number:
  (xxx-xx-xxxx)

 

Claimant Attorney Information
 
Attorney Name:
Address:
Town/State/Zip:
Phone:
FAX:

 

    
 
File Information
 
Insured:
Your File Number:
W.C.B. Number:
DOA (mm/dd/yy)
Venue:

 

   
Hearing Date: (yy/mm/dd)
Are Benefits Being Paid: Yes No
Treating Physician:
Initial Request: Yes      
Repeat Exam *: Yes
MMG File Number:


 
 


Specialty Required

Internal Medicine (01) Plastic Surgery (11)
Orthopedic (02) Ophthalmology (12)
Neurology (03) E.N.T. (13)
Surgery (04) Psychiatry (14)
Neurosurgery (05) Utilization Review (15)
Chiropractics (06) Physical Med. Rehab (16)
Cardiology (07) Acupuncture (17)
Dental (08) Other (Specify Below)
Radiology (09)    
Psychology (10)    

OTHER: 
 

    
 
Coverage & Issues
 
Workers Comp. No-Fault
Degree of Disability Need for Treatment
Causal Relationship Causal Relationship
Need for Treatment Can patient return to usual occupation
Schedule Loss Evaluation
Apportionment
M & S Issues
   
 

 

Liability Long Term Disability
Degree of Disability Work Status
Permanency Other
Causal Relationship    
Need for Treatment    

ANCR:

Medical records available on ecase Yes   No
 

    
 
Special Instructions










Thank you for making Medical Management Group your IME appointment service of choice.

NOTE: We suggest you print a copy of this assignment for your records. Click here ►

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