Referral for Independent Medical Evaluation

Below is the online referral form for Independent Medical Evaluation. The fields marked in red with a (*) are mandatory and require an entry. Please provide all available information as it will increase the efficacy of our initial review. There is a section below to upload documents such as medical records or other pertinent information. A coordinator will contact you within 24 business hours to confirm receipt of your information and discuss the referral.
  • Adjuster Information

  • Injured Worker Information

  • Independent Medical Evaluation

  • Medical Records & Claim Documents

  • Injured Worker’s Attorney

  • Accident Information

  • Medical Information/Treating Physician

  • Nurse Case Manager Information

  • Defense Attorney Information

  • By clicking submit you understand that you are submitting potentially sensitive information for the purpose requesting services from Labor Management Services, Inc. and you agree that you are authorized to disseminate this information. All supplied information is transmitted via Secure Socket Layer (SSL) technology. Please view our Privacy Policy for more information.