Physical/Occupational Therapy Referral

Neuropsychological IME/Peer Review
NES is proud to offer online referrals of the following services. This enables those organizations that our paperless or have scanned in medical records to upload their files directly to the treating therapist and minimize time spent organizing information for faxing and/or mailing. All information uploaded over the NES website is done so over a secured server that is HIPAA compliant. Upon receipt of your referral information NES will follow up with the referral source and schedule the subsequent evaluation within 24 hours. Same Neuropsychological IME/Peer Review HIPAA Compliance Information
Part 1 of 7
Referral Information
Referer:
Organization:
Name:
Address1:
Address2:
City:
State:
Zip Code:
Phone #:
Fax:
Email:
Part 2 of 7
Claimant Information
Name:
Address1:
Address2:
City:
State:
Zip Code:
Phone #:
Fax:
Email:
Part 3 of 7
Case Information
Adjuster:
Adjuster Phone #:
File/Claim No.:
Date of Birth:
Occupation:
Job Description:
Type of Injury:
How Injury Occurred:
Injury Date:
Diagnosis Code:
Diagnosis Description:
Insurer:
Attorney:
Attorney Phone #:
Include Attorney in Correspondence:	Yes No
Part 4 of 7
Employer Information
Name of Company:
Email:
Address1:
Address2:
Phone #:
Contact Person:
Are Physical Demands (or Job Demands) Available?	Yes No
Is this a job-specific IME?	Yes No
Part 5 of 7
Location:
Please select location:


Part 6 of 7
Type of Case
Liability LTD (Long Term Disability) STD (Short Term Disability) Long Shore State/Government Agency Legal Workers Compensation
Write in additional questions and/or information:


Medical Records Secure Upload We accept PDF, DOC and JPG format. File upload limit is 20MB
File #1:
File #2:
File #3:
File #4:
File #5:
File #6:

Important Note Hard copy information can be sent to the following: Fax: 603-742-1414 Mailing Address: Northeast Evaluation Specialists, PLLC 1 Washington St. Suite 443 Dover, NH 03820

Web Hosting Provided by Maine Hosting Solutions