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info@meritevals.com
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Call 402.827.3001
Who We Serve
Services
Why Merit Medical?
Learning
Learning
Join Merit’s Experts
Physicians
FAQs
Office Hours Program/Archive
News
Request Service
"
*
" indicates required fields
Requestor Information
Type of service
Independent Medical Exam (IME)
Virtual IME
Record Review
Impairment Rating / Causation
Second Opinion
Addendum
Phone Call
Requestor's name
First
Last
Requestor's phone
*
Requestor's fax
Requestor's email
*
Requestor's company name
*
Are you the contact person for this case?
*
Yes
No, I am requesting on behalf of...
Contact's name
First
Last
Contact's phone
Contact's fax
Contact's email
Contact's company name
Follow up communication preference
*
Phone
Email
No Preference
Preferred doctor or specialty
Injured Party Information
Injured Party's name
First
Last
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Please note: We do not contact the Injured Party. Contact details are collected solely to prevent duplicate entries in our system.
Does the injured party need an interpreter?
*
Yes
No
Interpreters must be coordinated by the Requestor.
Injured Party's date of birth
*
MM slash DD slash YYYY
Date of injury
*
MM slash DD slash YYYY
Number of body parts involved:
*
1
2
3
4
5+
Injury / Body Part(s)
*
Indicate left or right, and separate multiple body parts with commas.
Case claim number
*
Type of Claim
*
Personal Injury
Workers' Compensation
Number of pages of medical records
*
0 - 500 Pages
501 - 1,000 Pages
1,001 - 2,500 Pages
Over 2,500 Pages
How do you plan to send the records?
*
Electronically
Deliver hard copy records
Sending records electronically is subject to a $0.60 per-page fee, plus an administrative fee for submissions of 250 pages or more. Hard copies can be mailed to: 12103 Anne Street, Omaha, NE 68137.
A cover letter is required before the case can be assigned. Is the cover letter prepared and ready?
Yes, I will upload the letter
Not yet, but the letter will be sent as soon as possible
The cover letter should summarize the injury details and outline the specific questions being asked of the doctor.
Upload cover letter
Max. file size: 300 MB.
Is the Injured Party represented by an attorney?
*
Yes
No
Name of Injured Party's legal representation
First
Last
Phone
Please note that we do not contact the Injured Party's legal representation.
Payer Information
Who should receive the invoice?
*
Same as Requestor
Different than Requestor
If different than Requestor, who should receive the invoice?
First
Last
Payor phone number
Payor email address
Have you previously referred to Merit Medical Evaluations?
*
Yes
No
If no, how did you learn about Merit Medical Evaluations?
If referred by a colleague, please include their name.
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