Employer Request for Independent Medical Exam

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Company Information

Please complete the information below, if you wish to request that an employee be evaluated by a physician selected by this agency. Be sure to complete all the information, including the reason why you feel this examination is necessary.

**
(First, Middle, Last)
Name of your employee
**
-- (xxx-xx-xxxx)
Social Security Number
**
(MM/DD/YYYY)
First day of disability
**
Comments explaining the reason for independent medical exam
**
Name of the agency or company
**
(First, Middle, Last)
Contact information of the individual making the request
**
Contact number of the individual making the request
(333)333-3333
Electronic mailing address of the individual making the request
yourname@abc.com

(** indicates a required field)

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