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Schedule an IME Service

The following online form is available to expedite your scheduling needs. Username and password are optional. After we receive your service request, a MedEx representative will personally contact you to complete and confirm your order. An online request is not a completed order until it has been authorized and confirmed by a MedEx representative.

We respect your privacy, and your information is encrypted before it is sent to MedEx. Please view our privacy statement for more information.

Saving and Retrieving Referral Information
If you plan on completing this form multiple times, you can provide a username and password below, and MedEx will save your input for the Referral Information section of the form. After providing your username and password, please continue filling out the form, and your account will be created when the form is submitted. You can retrieve this information by logging in here. The Referral Information section will then be filled in with the values that you used previously.

New Account
Username
Password
Confirm Password
Existing Account

Log In

Referral Information
Name
Company
Address
City
State
Zip Code
Phone (123-456-7890)
Extension
Fax (123-456-7890)
Email

Service Information
Service Type Independent Medical Evaluation
Record Review
Supplemental Report
Deposition
Case Type Worker's Compensation
Personal Injury / No-Fault
Disability / Malpractice
Other
Doctor Specialty
Doctor Preference
Scheduling Timeframe (IME Calendar - Opens in new window)
Report Due Date (if any) (mm/dd/yy)
Will a nurse case manager be attending the IME appointment?
Yes(nurse's name)
No
Special Instructions
Will you be utilizing our cover letter service?
Yes
No

Claimant Information
First Name
Last Name
Gender Male
Female
Address
City
State
Zip Code
Phone (123-456-7890)
Birth Date (mm/dd/yy)
SSN (123-45-6789)
Type of Injury
Date of Injury (mm/dd/yy)
Claim Number
Claim State Wisconsin Claim
Minnesota Claim
Other
Employer
Treating Practitioner
Attorney
Would you like us to send the claimant a reminder letter and
location map one week prior to the IME?
Yes
No
Would you like us to call the claimant with an appointment
reminder three days prior to the IME?
Yes
No

Additional Information
How did you hear about MedEx?
Current Client
Previous Client
Referred By
Scheduling Confirmation Email
Fax
Phone

Human Challenge
Please enter the terms you see in the box below, in order and separated by a space. Doing this helps prevent automated programs from abusing this service.

  • If you are not sure what the terms are, either enter your best guess or click the reload button below the distorted words.
  • Visually impaired users can click the audio button to hear a set of numbers that can be entered instead of the visual challenge.
  • If you plan to fill out this form multiple times, you can bypass this "Human Challenge" in the future by creating an account at the top of this page.