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info@meritevals.com • Call 402.827.3001

Who We Serve
Services
Why Merit Medical Evaluations
Learning

Request an Independent Medical Exam or Case Review

Request an independent medical exam (IME) or medical record review using the form below. Merit Medical Evaluations provides efficient, physician-led evaluations for legal and insurance cases.

Click Here to view our specialists by specialty.

Submit Your Request

Use this form to request an independent medical exam or medical record review. Our team will coordinate the evaluation and handle all necessary logistics.

"*" 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 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:*

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*

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. Single-sided 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.

Δ

Name

First Last

Email(Required)

Δ

12103 Anne Street
Omaha, NE 68137

info@meritevals.com

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