Referral Request Form

Complete the referral request form below to submit a request for an independent medical evaluation.

Our mission at ManageAbility IME is to provide the claims industry with access to local accredited healthcare professionals who offer expertise in conducting independent medical evaluations, medical record reviews, and radiology reviews. ManageAbility IME is dedicated to meet and exceed our clients’ expectations with high standards of excellence and professionalism. We will handle your referral request promptly and with utmost professionalism.

Claimant Information

Employment Information

Client Information

Questions to be Addressed

Please check the question(s) below that you would like the physician to address in his/her report:

Supporting Documentation

Please attach any supporting documentation (Medical records, photographs, etc.)

Additional Comments

Attorney Information (If Applicable)

Nurse Case Manager Information (If Applicable)