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SERVICES
IMEs
Peer and Radiology Reviews
ABOUT
YOUR EXAM
OUR PROVIDERS
CONTACT
REFERRALS
Referrals
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2021-02-25T01:22:37+00:00
Referrals
Please complete the following form. A Tri-County Associates of Medicine representative will process the information provided and contact you as soon as possible with scheduling information.
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Referral Source Information
Name
*
First
Last
Email
*
Company
Phone
Fax
Claimant Information
Name
First
Last
Phone
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Last four of S.S.N
D.O.B
Gender
Male
Female
Claim Information
Claim Number
Date of Injury
Type of Case
Auto
Work Comp
Liability
Other
Type of Service
IME
Record Review
Film Review
Treating Physician/Specialty
Description of Injury
Body parts to be examined
Litigated?
Yes
No
Notification Information
Plaintiff Attorney Name
Plaintiff Attorney Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Defense Attorney Name
Defense Attorney Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Other Party Name (1)
Other Party Address (1)
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Other Party Name (2)
Other Party Address (2)
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Confirmation Letter to be sent to claimant?
Yes
No
Confirmation letter to be sent to? (select all that apply)
Plaintiff
Defense
Other Parties
Instructions
Examiner requested (if any)
Specialty Requested
Orthopedic Surgery
Physical Medicine & Rehabilitation
Psychiatry
Psychology
Neuropsychology
Podiatry
Chiropractic
Dermatology
Neurology
Neurological Surgery
Internal Medicine
Pain Medicine
Radiology
Neuroradiology
Infectious Disease
Oncology
Allergy & Immunology
Hand Surgery
Otolaryngology
Dentistry
Ophthalmology
Oral Surgery
Cardiology
Pulmonology
Occupational Medicine
General Surgery
Neuro-Ophthalmology
Anesthesiology
Emergency Medicine
Family Medicine
Gastroenterology
Rheumatology
Obstetrics & Gynecology
Plastic Surgery
Medical Records
Pick Up
Mail
Fax
Upload Electronically
Transportation Needed?
Yes
No
Interpreter Needed?
Yes
No
If interpreter needed, which language?
Other Instructions
After submitting your information, you will have the opportunity to upload and send additional documents if you would like.
Submit
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