IME Examination Request

Today’s Date: 

Claimant:

Address:  

City:

State:  Zip/Postal code: 

Employer:

Address:  

City:

State: Zip/Postal code: 

Injury:

Your Name: 

Company/ Firm: 

Address:  

City:

State: Zip/Postal code:

Phone: 

Fax: 

Email:

Home#: 

Work#: 

Date of Birth:

SS# 

DOI: 

Personal Injury

Auto State:

W/C Claim#

Date Exam Needed By:

Location Requested:

Mt Lebanon Clairton

Charleroi      Uniontown

Physician requested: 

Scott L. Baron, M.D.

Thomas F. Brockmeyer, M.D., Ph.D.

Allan H. Tissenbaum, M.D.

Alex Kandabarow, M.D.