IME Logix, eClaims for IME Vendors
eClaims Logo
- 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
SecureDoc Forms
You will not be able to track this message because you are not currently logged in. Click here to log in
AssessMed
Call Us Toll-Free: 1-888-678-2924
Referral Form
Referral Date:   (mm/dd/yyyy)
Evaluee
*Name:
*Date of Birth: Gender:
Address 1:
Address 2:
Telephone:    
*Date of Loss: *File Number:
Pre-Injury Occupation:    
Impairment:
Employer Information
Company Name:
Contact Name:
Address 1:
Address 2:
Telephone: Fax:
Email:
Examinee Treating Physician
Name:
Address 1:
Address 2:
Telephone: Fax:
Type of Assessment
 
  
 
Other:
Additional Services To Be Arranged AssessMed
Interpreter Required?
Language:  
Transportation Required?
   
Accommodation Required?
   
Final Report / Special Instructions
 
 
Optional Referral Questions
FULL MEDICAL REPORT QUESTIONS
Please select any questions you would like the evaluator(s) to answer in the final report:
NON MEDICAL REPORT QUESTIONS
Please select any questions you would like the evaluator(s) to answer in the non-medical summary:
Additional Questions:
In addition to any medical information you have, please also forward to our office a full job descriptions and/or Physical Demands Analysis (PDA) if you have one completed. If you do not have one completed, please advise and AssessMed can provide one for you at an additional cost.
  
© 2022 SecureDocs. All rights reserved