- Modern case management software for the Canadian IME Vendor
- Automation manages doctors, appointments, documents, and tracks costs
- PIPEDA and HIPAA compliant, cloud hosted with SOC audits included

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Referral Date:

(mm/dd/yyyy)

Insurer Information
*Company Name:
Address 1:
Address 2:
City:		Province:	ABBCMBNBNFNSNTNUONPEQCSKYT
Postal Code:
*Adjuster's First Name:		*Adjuster's Last Name:
*Telephone:		Cell or Other Phone:
Email:		Fax:

Claimant Information
*First Name:		*Last Name:
Gender:	Male Female	*Date of Birth:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Address 1:
Address 2:
City:		Province:	ABBCMBNBNFNSNTNUONPEQCSKYT
Postal Code:		Email:
Telephone:		Claimant Cell or Other Phone:
*Date of Loss:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	*Claim Number:
Diagnosis, Description of Injury, Special Requests

Legal Representation
Law Firm:
First Name:		Last Name:
Address 1:
Address 2:
City:		Province:	ABBCMBNBNFNSNTNUONPEQCSKYT
Postal Code:
Telephone:		Cell or Other Phone:
Email:		Fax:

Assessments Type
Exam Type	IME Job Site Analysis FAE In Home Assessment
Specialty Type (for IME & CE only)
Dentistry (IDE) Labour Market Survey Ophthalmology Physiatry Respirology Gastroenterology Neurology Oral Surgery Plastic Surgery Rheumatology General Practitioner Neuropsychology Orthopedic Surgery Psychiatry Transferable Skills Analysis General Surgery Neurosurgery Otolaryngology (ENT) Psychology Vocational Internal Medicine Occupational Medicine Pediatrics Psychovocational
Other:
Diagnostics Imaging
Bone Scan CT Scan MRI X-ray

Additional Services To Be Arranged By A.R.S.
The following services will be arranged by A.R.S. at no additional administrative cost.
Interpreter Required?	Yes No		Language
Transportation Required?	Yes No	Ground Air	Pickup Address:
Accommodation Required?	Yes No		Instructions:
Would you like A.R.S. to initiate direct contact with the claimant strictly to communicate the appointment details?			Phone Letter Phone or Letter No Direct Contact

Comments / Special Instructions

Optional Referral Questions

IME Referral Questions

Within the scope of your medical discipline, what is/are the examinee’s diagnosis/diagnoses? Within the scope of your medical discipline, what is the examinee’s prognosis? Has maximum medical recovery been reached? Are the reported symptoms consistent with the diagnosis? Is the claimant partially or totally and wholly disabled? If disabled, what activities are restricted and/or limited and why? What is the anticipated duration of the restrictions/limitations? Is the claimant able to return to work on a part time or graduated basis? If the claimant is wholly and totally disabled, what is the estimated date of return to work? Are there any obstacles preventing a return to work? Please comment on the past and current treatment, including nature, frequency and duration. What are your recommendations for treatment? Specifically describe the nature, frequency and duration of the prescribed treatment.

Causation Questions

Is the injury a result of the MVA? Or is the injury a consequence of a pre-existing condition? Is there a pre-existing condition impacting the return to pre-accident function? If yes, please elaborate.

Additional Questions: