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Request Type
Independent Medical Examination
Medical Record Review
Medical Chronology
Medical Bill Review
Other
Other
Your Name
Email
Phone
Firm
Role
Defense Attorney
Plaintiff Attorney
Claims Adjuster
Pro-Se Party
Other
Paralegal Name
Paralegal Email
Paralegal Phone
Permission to coordinate directly with opposing counsel for scheduling purposes
Yes
No
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Case Title
Injured Party Name
Case Number
Cause Number
Date of Loss
MM
/
DD
/
YYYY
DOB
MM
/
DD
/
YYYY
Case Type
Trial
Arbitration
Mediation
Event Date
MM
/
DD
/
YYYY
Venue
Federal
State
Other
Venue Note
Adjuster Name
Adjuster Email
Other Parties
Direct Bill Adjuster?
Yes
No
Split Invoice?
Yes
No
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Type of Injury / Issues
Specialty(s) or Requested Expert(s)
Exam Location
Report Due Date
Tab/Select Date Components
MM
/
DD
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YYYY
Report Format
Written
Verbal
Stipulation?
Yes
No
Order Entered?
Yes
No
Discovery Cutoff Date
Tab/Select Date Components
MM
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DD
/
YYYY
Testimony Requested
Yes
No
Testimony Date
Tab/Select Date Components
MM
/
DD
/
YYYY
Records Status
Available
Pending Retrieval
Records Size (Inches)
Comments
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Opposing Attorney Name
Opposing Firm
Opposing Attorney Email
Opposing Attorney Phone
Opposing Paralegal Name
Opposing Paralegal Email
Opposing Paralegal Phone
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