Independent Medical Evaluation Request Form Patient Name Condition(s) being evaluated Worker´s Compensation Claim Number Social Security Number Employer Preferred Date(s) for Evaluation Please check the preferred location for the evaluation to be performed. Akron Canton Columbus Austintown/Youngstown Toledo Solon Cleveland/Euclid Middleburg Heights Mansfield Your Name Your Company or Firm Your Telephone Number Your Email Address Your request will be confirmed by telephone within 24 hours of submission by our Independent Medical Evaluation Coordinator. Click Below to View Maps of Our Office Locations Cleveland Solon Middleburg Hts. Canton Austintown Mansfield Columbus Toledo Please email us with any questions or to schedule an evaluation or exam. VARTEXT7 VARTEXT8 VARTEXT9 Independent Medical Evaluation Request Form Patient Name Condition(s) being evaluated Worker´s Compensation Claim Number Social Security Number Employer Preferred Date(s) for Evaluation Please check the preferred location for the evaluation to be performed. Akron Canton Columbus Austintown/Youngstown Toledo Solon Cleveland/Euclid Middleburg Heights Mansfield Your Name Your Company or Firm Your Telephone Number Your Email Address Your request will be confirmed by telephone within 24 hours of submission by our Independent Medical Evaluation Coordinator. Click Below to View Maps of Our Office Locations Cleveland Solon Middleburg Hts. Canton Austintown Mansfield Columbus Toledo Please email us with any questions or to schedule an evaluation or exam. 0 Independent Medical Evaluation Request Form Patient Name Condition(s) being evaluated Worker´s Compensation Claim Number Social Security Number Employer Preferred Date(s) for Evaluation Please check the preferred location for the evaluation to be performed. Akron Canton Columbus Austintown/Youngstown Toledo Solon Cleveland/Euclid Middleburg Heights Mansfield Your Name Your Company or Firm Your Telephone Number Your Email Address Your request will be confirmed by telephone within 24 hours of submission by our Independent Medical Evaluation Coordinator. Click Below to View Maps of Our Office Locations Cleveland Solon Middleburg Hts. Canton Austintown Mansfield Columbus Toledo Please email us with any questions or to schedule an evaluation or exam. 1 Independent Medical Evaluation Request Form Patient Name Condition(s) being evaluated Worker´s Compensation Claim Number Social Security Number Employer Preferred Date(s) for Evaluation Please check the preferred location for the evaluation to be performed. Akron Canton Columbus Austintown/Youngstown Toledo Solon Cleveland/Euclid Middleburg Heights Mansfield Your Name Your Company or Firm Your Telephone Number Your Email Address Your request will be confirmed by telephone within 24 hours of submission by our Independent Medical Evaluation Coordinator. Click Below to View Maps of Our Office Locations Cleveland Solon Middleburg Hts. Canton Austintown Mansfield Columbus Toledo Please email us with any questions or to schedule an evaluation or exam. 2 Independent Medical Evaluation Request Form Patient Name Condition(s) being evaluated Worker´s Compensation Claim Number Social Security Number Employer Preferred Date(s) for Evaluation Please check the preferred location for the evaluation to be performed. Akron Canton Columbus Austintown/Youngstown Toledo Solon Cleveland/Euclid Middleburg Heights Mansfield Your Name Your Company or Firm Your Telephone Number Your Email Address Your request will be confirmed by telephone within 24 hours of submission by our Independent Medical Evaluation Coordinator. Click Below to View Maps of Our Office Locations Cleveland Solon Middleburg Hts. Canton Austintown Mansfield Columbus Toledo Please email us with any questions or to schedule an evaluation or exam. 3 Independent Medical Evaluation Request Form Patient Name Condition(s) being evaluated Worker´s Compensation Claim Number Social Security Number Employer Preferred Date(s) for Evaluation Please check the preferred location for the evaluation to be performed. Akron Canton Columbus Austintown/Youngstown Toledo Solon Cleveland/Euclid Middleburg Heights Mansfield Your Name Your Company or Firm Your Telephone Number Your Email Address Your request will be confirmed by telephone within 24 hours of submission by our Independent Medical Evaluation Coordinator. Click Below to View Maps of Our Office Locations Cleveland Solon Middleburg Hts. Canton Austintown Mansfield Columbus Toledo Please email us with any questions or to schedule an evaluation or exam. 4 Independent Medical Evaluation Request Form Patient Name Condition(s) being evaluated Worker´s Compensation Claim Number Social Security Number Employer Preferred Date(s) for Evaluation Please check the preferred location for the evaluation to be performed. Akron Canton Columbus Austintown/Youngstown Toledo Solon Cleveland/Euclid Middleburg Heights Mansfield Your Name Your Company or Firm Your Telephone Number Your Email Address Your request will be confirmed by telephone within 24 hours of submission by our Independent Medical Evaluation Coordinator. Click Below to View Maps of Our Office Locations Cleveland Solon Middleburg Hts. Canton Austintown Mansfield Columbus Toledo Please email us with any questions or to schedule an evaluation or exam. 5 Independent Medical Evaluation Request Form Patient Name Condition(s) being evaluated Worker´s Compensation Claim Number Social Security Number Employer Preferred Date(s) for Evaluation Please check the preferred location for the evaluation to be performed. Akron Canton Columbus Austintown/Youngstown Toledo Solon Cleveland/Euclid Middleburg Heights Mansfield Your Name Your Company or Firm Your Telephone Number Your Email Address Your request will be confirmed by telephone within 24 hours of submission by our Independent Medical Evaluation Coordinator. Click Below to View Maps of Our Office Locations Cleveland Solon Middleburg Hts. Canton Austintown Mansfield Columbus Toledo Please email us with any questions or to schedule an evaluation or exam. 6 Independent Medical Evaluation Request Form Patient Name Condition(s) being evaluated Worker´s Compensation Claim Number Social Security Number Employer Preferred Date(s) for Evaluation Please check the preferred location for the evaluation to be performed. Akron Canton Columbus Austintown/Youngstown Toledo Solon Cleveland/Euclid Middleburg Heights Mansfield Your Name Your Company or Firm Your Telephone Number Your Email Address Your request will be confirmed by telephone within 24 hours of submission by our Independent Medical Evaluation Coordinator. Click Below to View Maps of Our Office Locations Cleveland Solon Middleburg Hts. Canton Austintown Mansfield Columbus Toledo Please email us with any questions or to schedule an evaluation or exam. 7 Independent Medical Evaluation Request Form Patient Name Condition(s) being evaluated Worker´s Compensation Claim Number Social Security Number Employer Preferred Date(s) for Evaluation Please check the preferred location for the evaluation to be performed. Akron Canton Columbus Austintown/Youngstown Toledo Solon Cleveland/Euclid Middleburg Heights Mansfield Your Name Your Company or Firm Your Telephone Number Your Email Address Your request will be confirmed by telephone within 24 hours of submission by our Independent Medical Evaluation Coordinator. Click Below to View Maps of Our Office Locations Cleveland Solon Middleburg Hts. Canton Austintown Mansfield Columbus Toledo Please email us with any questions or to schedule an evaluation or exam. 8 Independent Medical Evaluation Request Form Patient Name Condition(s) being evaluated Worker´s Compensation Claim Number Social Security Number Employer Preferred Date(s) for Evaluation Please check the preferred location for the evaluation to be performed. Akron Canton Columbus Austintown/Youngstown Toledo Solon Cleveland/Euclid Middleburg Heights Mansfield Your Name Your Company or Firm Your Telephone Number Your Email Address Your request will be confirmed by telephone within 24 hours of submission by our Independent Medical Evaluation Coordinator. Click Below to View Maps of Our Office Locations Cleveland Solon Middleburg Hts. Canton Austintown Mansfield Columbus Toledo Please email us with any questions or to schedule an evaluation or exam. 9 0 1