Medical Document Automation
eClaims Logo
is now connected with
Wisedocs Logo
- Automatically organize and index med/legal documents
- Sorting, de-duplication, and classification including OCF forms
- Fast turn-around with ability to update with addendums
SecureDoc Forms
You will not be able to track this message because you are not currently logged in. Click here to log in
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:
  
© 2022 SecureDocs. All rights reserved