Insurance Request Form

Requester’s Information

Claimant’s Information

Claimant’s Attorney Information

Claim Information

Other Specialties:

Requested Services

 Yes    No       Would you like PDS to copy your file, free of charge?

 Yes    No       Would you like PDS to send the claimant a notification letter?

 Yes    No       Would you like PDS to place a reminder call to the claimant?

 Yes    No       Would you like PDS to send the attorney a notification letter?

 Yes    No       Would you like PDS to place a reminder call to the attorney?

If an interpreter is needed, please specify language:


Please list injured body part(s), describe injury, and anything else important.

PIP IME Cover Letter

Please check the questions below that you would like the Doctor to address.

    What injuries were sustained in the accident in question and what is the current status of those injuries?

    What was the mechanism of injury pertaining to the accident-related injuries?

    Were the treatment and diagnostic studies received by claimant for the subject accident considered reasonable and necessary for the injuries sustained in the accident? If not, please specify what has been reasonable and necessary, and why.

    Did claimant suffer from any pre-existing injuries or conditions prior to the subject accident? If so, please identify those injuries and/or conditions and, if possible, provide a status of those injuries at the time of the subject accident.

    Has the claimant reached maximum medical improvement from the medical care, chiropractic care, and/or physical therapy treatment relative to any injuries sustained in the accident in question? If yes, when? If no, when would it be reasonable to expect the claimant to be at MMI?

    Is any additional treatment necessary relative to any injuries sustained in the accident in question? If so, please specify the type, frequency, and duration of that care.

    Are any additional ancillary or diagnostic tests required? If so, please explain.

    Is the claimant capable of working? If only with restrictions, please specify those restrictions, describing particular physical limitations (i.e. lifting, pushing, pulling, etc.), and comment on the expected duration of the restrictions. Are these restrictions necessary as a result of the accident?

    Is the claimant capable of performing activities of daily living? If only with restrictions, please specify those restrictions and comment on the expected duration of the restrictions. Are these restrictions necessary as a result of the accident?

Other Questions

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