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direct IME
Direct IME
3760 14th. Ave., Suite 201
Markham, ON L3R 3T7
Phone: 416-609-3211
Toll Free: 1-888-253-4470
Fax: 416-609-9021
Toll Free Fax: 1-855-609-9021
Email: service@directime.ca
Online Referral Form
Referral Date:   (mm/dd/yyyy)
Claimant/Employee Information
Salutation: Date of Birth:
*First Name: *Last Name:
Job Title:
Address:
City: Province:
Postal Code:  
Telephone: Cell Phone:
Fax: Email:
Claim Number: Policy Number:
Date of Loss:
Referral Source
*Company Name:
Claim Type:
*Referral Contact:
Address 1:
Address 2:
City: Province:
Postal Code:  
*Telephone: Cell Phone:
Email: Fax:
Insurance Company:
Insured's Name:
Policy Number:
Employer Information (if applicable)
Company Name:
Address 1:
Address 2:
City: Province:
Postal Code:  
Telephone: Cell Phone:
Email: Fax:
Legal Information (if applicable)
Firm Name:
Address 1:
Address 2:
City: Province:
Postal Code:  
Telephone: Cell Phone:
Email: Fax:
Type of Assessment
 
 
Reason for Assessment
 
Dated:
Dated:
Dated:
Other:
Services Requested
 
 
Other:
Additional Services To Be Arranged By Direct IME
Interpreter Required?
  Language
Transportation Required?
Pickup Address:
Accommodation Required?
  Instructions:
Communication Instructions
Assessment Confirmation To Be Sent By:
 
Claimant Notice of Assessment Letter:
Medical File To Be Received By:
 
Comments / Special Instructions
Optional Referral Questions
Med-Rehab Questions
Specified Benefits Questions
Additional Questions:
  
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