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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:
Mr.
Mrs
Ms
Miss
Dr.
Date of Birth:
*
First Name:
*
Last Name:
Job Title:
Address:
City:
Province:
AB
BC
MB
NB
NF
NS
NT
NU
ON
PE
QC
SK
YT
Postal Code:
Telephone:
Cell Phone:
Fax:
Email:
Claim Number:
Policy Number:
Date of Loss:
Referral Source
*
Company Name:
Claim Type:
Auto
LTD/STD
Legal
Employer
WSIB
3rd Party
*
Referral Contact:
Address 1:
Address 2:
City:
Province:
AB
BC
MB
NB
NF
NS
NT
NU
ON
PE
QC
SK
YT
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:
AB
BC
MB
NB
NF
NS
NT
NU
ON
PE
QC
SK
YT
Postal Code:
Telephone:
Cell Phone:
Email:
Fax:
Legal Information (if applicable)
Firm Name:
Address 1:
Address 2:
City:
Province:
AB
BC
MB
NB
NF
NS
NT
NU
ON
PE
QC
SK
YT
Postal Code:
Telephone:
Cell Phone:
Email:
Fax:
Type of Assessment
Insurer Examination (S.44, Ontario Auto)
IME, MSE, CE (Alberta)
Medico-Legal
STD-LTD
Reason for Assessment
Applicability of the Minor Injury Guideline
Dated:
Treatment and Assessment Plan OCF-18
Dated:
Application of Catastrophic Impairment OCF-19
Dated:
Disability Status
Post 104
Caregiver Benefits
Attendat Care Benefits
Housekeeping/Home Maintenance
Income Replacement Benefits
Non-Earner Benefits
Other:
Services Requested
Addiction Medicine
Opthalmology
Cardiology
Orthopaedic
Chiropractic
OT - In Home Assessment
Chronic Pain
OT - In Home (Form 1)
FAE (1 day)
Otolaryngology
FAE (2-3 days)
Physiatry
Gastroenterology
Physiotherapy
General Physician/Family or Occupation Medicine
Psychiatry
Internal Medicine
Psychology
Job Site Analysis
Psychovocational Assessment
Job Site Training
Respirology
Labour Market Survey
Rheumatology
Neurology
Transferable Skills Analysis
Neuropsychology
Vocational Assessment
Neurosurgery
Other:
Additional Services To Be Arranged By Direct IME
Interpreter Required?
Yes
No
Language
Transportation Required?
Yes
No
Ground
Air
Pickup Address:
Accommodation Required?
Yes
No
Instructions:
Communication Instructions
Assessment Confirmation To Be Sent By:
Email
Fax
SecureDocs
Claimant Notice of Assessment Letter:
Required from Direct IME
Not required from Direct IME
Medical File To Be Received By:
Courier
Email
Fax
SecureDocs
Comments / Special Instructions
Optional Referral Questions
Med-Rehab Questions
Based on your interview, examination and review of the clinical notes provided, are the goods and services detailed in the OCF-18 in question reasonable and necessary as a direct result of injuries sustained in the accident?
Does the claimant have predominantly a minor injury to which the Minor Injury Guideline (MIG) applies?
If not a minor injury, please provide compelling evidence to explain same. Please provide your opinion regarding why the claimant is unable to reach maximal medical recovery within the MIG.
If not a minor injury, is the attached Treatment and Assessment Plan reasonable and necessary as a result of the injuries sustained in this motor vehicle accident?
Specified Benefits Questions
Based on your interview, examination and review of the clinical notes provided, please provide your diagnosis and prognosis of the injuries sustained as a result of the motor vehicle accident.
Based on your interview, examination and review of the clinical notes provided, does the claimant currently suffer an impairment as a direct result of injuries sustained in this accident that causes a substantial inability to engage in the essential tasks of her employment?
Based on your interview, examination and review of the clinical notes provided, does the claimant currently suffer an impairment sustained in this accident that causes a substantial inability to engage in the care giving activities in which the claimant normally engaged at the time of the accident?
Based on your interview, examination and review of the clinical notes provided, does the claimant suffer from a complete inability to carry on a normal life as a direct result of injuries sustained in the accident?
Based on your interview, examination and review of the clinical notes provided, does the claimant suffer from an impairment sustained in this accident that causes a substantial inability to perform housekeeping and home maintenance services normally performed before the accident?
Based on your interview, examination and review of the clinical notes provided, does the claimant suffer an impairment as a direct result of injuries sustained in the accident that results in the need for attendant care assistance? Your response must include a completed Form 1 to precisely detail the level of assistance required.
Based on your interview, examination and review of the clinical notes provided, does the claimant suffer from an impairment sustained in this accident that causes a complete inability to engage in any occupation for which they are reasonably suited by education, training and experience?
If a disability has been identified, please detail any medical restrictions and/or functional limitations that prevent these activities from being performed and the recommended hours of assistance required per week and when the claimant should be able to perform these independently.
If a disability has been identified, please provide detailed recommendations to eliminate the disability (frequency and duration of any recommended treatment).
Additional Questions:
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