Coverage Area



RKI Claims
Specialists, LLC


Address: P.O. Box 222666
Chantilly, VA
20153
 
Telephone: 866.364.8567
Fax: 866.364.8570

IME REFERRAL

Adjuster's Information Nurse Case Manager Infomation
Name:
Company:
Email:
Phone:
Fax:
Name:
Company:
Email:
Phone:
Fax:
Defense Attorney Infomation Claimant's Attorney Infomation
Name:
Company:
Email:
Phone:
Fax:
Name:
Phone:
Fax:
Claimant Infomation
Name:
Address:
Phone 1:
Phone 2:
DOB:
SS Number:
DOI:
Injury Date:
Nature of Injury:
Claim #:
Jurisdiction:
Area(s)of Body: Head Cervical Thoracic Lumbar Elbow
Hand Ankle Foot Knee Shoulder
Other  
Side of Body: Left Right
Specialty Requested: Orthopedic Neurosurgeon Psych Neurologist
Other  
Hearing Date:
Translator Needed:
Yes No Translation Language:
Transportation Needed:
Yes No
Who is writing the cover letter? Adjuster Nurse Case Manager Defense Attorney RKI Other
Issues to be raised? Diagnosis-Prognosis-History
Causal Relation/Pre-existing condition
Return to Work (restrictions if needed)
Preliminary RTW needed
Need for future treatment
Maximum Medical Improvement-If not when
PPD Rating  - Areas to be rated
Apportionment
Previous Award
Other  
Comments:
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