Referral Form – Logical IME

Carrier

Adjuster Name

Adjuster Email *

Adjuster Phone

Specialty

Physician Preference

Due

Referral Type

Please Have Physician Complete

Exhibit Q

Narrative Report

Claim # *

DOI/DOD *

Benefit State *

Claimant Last Name

Claimant First Name

Claimant Phone

DOB *

Purpose of exam

(This line will be printed on the Employee Notice for Vermont Claims)

Claimant Address

Claimant City

State

Claimant Zip

Body Part *

Diagnosis

Employer

Job Title

Case Summary

Is Translation Required?

Yes

Is Transportation required?

Yes

Transportation/ Translation Vendor

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Your preferred vendor

Is the claimant represented by an Attorney? *

Yes

Attorney Name

Attorney Phone

Cover Letter

I will supply my own cover letter within 1 week of this referral

I will use this referral form to build my own cover letter

Would you like the case summary you entered above printed on the Cover Letter?

Yes

Cover Letter Upload

Custom Questions:

Please provide your custom questions to be added to the cover letter:

Rotator Cuff Injury

Regarding the right/left shoulder films that have been provided for your review, please interpret the films and determine if there is any significant difference between his/her pre work-related condition and post work-related condition. Please explain in detail.

In your expert opinion, has the claimant engaged in any other outside recreational / personal activity that could have contributed to the current diagnosis in regards to his/her shoulder injury (ie sports, house maintenance)?

Since the date of injury, has it been determined if the claimant has engaged in activity, personal or work that would have contributed to a further decline in condition in relation to the shoulder (ie extensive reaching, lifting) against physician recommendation?

Are there any findings that would report pre-existing conditions? If so, please provide your professional opinion.

Please identify if any further diagnostics are required to more accurately assess the claimant’s current diagnosis in regards to the shoulder?

KNEE - MENISCECTOMY/ACL

What are the claimant’s current subjective complaints regarding the injured knee? Do these complaints differ from your professional objective findings? If so, please explain.

In reviewing the films and in considering both objective findings and current subjective symptoms reported by the claimant, do you believe there are pre-existing contributing factors for the claimant’s current diagnosis in relation to the injured knee such as weight control, prior injury, or personal health related conditions?

ELBOW – Ulnar/Epicondylitis

In your professional opinion, and in reviewing the claimant’s medical history and prescription drug usage, has the claimant been actively taking any medication that could have contributed to overall muscle atrophy, resulting in a diagnosis of epicondylitis?

Per interview of the claimant, have any personal activities been identified that could have caused or exacerbated the current diagnosis in relation to the affected elbow?

In your expert opinion, has the claimant undergone all means of conservative treatment for the elbow/ ulnar nerve pain to include medication management, vitamin supplementation, splinting, and physical therapy and rehabilitation?

If the claimant is a surgical candidate for epicondyle repair (or ulnar nerve transposition), please specify post-operative treatment timeframes for a return to functional use/return to work in regards to the rehabilitation process?

PSYCHIATRIC

Does this claimant exhibit any criteria from the DSM ( The Diagnostic and Statistical Manual of Mental Disorders (DSM)is the standard of classifications of mental disorders used by mental health professionals in the United States)?

Does the injured worker display any deficits in cognitive, motor, behavioral, linguistic or executive functioning?

Which part(s) of the brain are affected or these changes to be expressed?

Is a neuropsychological evaluation indicated?

If deficits are displayed, what is the best treatment path to follow?

Are these deficits, if any, pre-existing?

What is the timeframe for recovery to pre-injury function?

Is a physical rehabilitation, or reconditioning program indicated?

How does the worker describe his or her personality before their injury, How does their injury affect their job, what are their ambitions regarding employment?

LOWER EXTREMITY/FRACTURE

Is there any long term deficit expected due to this injury?

CARPAL TUNNEL SYNDROME

Recently, there are studies which demonstrated the CTS is caused by certain genetic predispositions and some life style choices, not necessarily just by the work environment. Which of these factors are attributing to the current injury?

Is a cortisone injection into the CT indicated?

LUMBAR STRAIN

Is there evidence of pre-existing degeneration disk disease or spondylosis? Is the current disability a result of the work injury, or are there pre-existing issues?

If the person has pre-existing diabetic neuropathy- I would ask if the current radicular symptoms are a result of pre-existing diabetic neuropathy?

CERVICAL STRAIN

Is there evidence of pre-existing degeneration disk disease or spondylosis? Is the current disability a result of the work injury, or are there pre-existing issues?

If the person has pre-existing diabetic neuropathy- I would ask if the current radicular symptoms are a result of pre-existing diabetic neuropathy?

POST CONCUSSION SYNDROME

Are all symptoms related to diagnosis?

Are there pre-existing conditions contributing to ongoing symptoms?

Has treatment been reasonable and necessary?

What additional treatment is recommended and for how long?

Has the patient reached MMI? When do you anticipate this patient will reach MMI?

What is the current work capacity?

How long will restrictions remain in effect and will this patient ever RTW?

Note: In many of the situations with a post-concussion diagnosis, there is almost always a prior history of depression or anxiety or both. When this is present, it always impacts recovery.

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