Employer Referral Form

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NON MEDICAL SUMMARY ONLY to be released to the referral source (full Medical report will be forwarded to the examinee's treating physician)

Within the scope of your medical discipline, what is examinee’s primary & secondary diagnosis

Within the scope of your medical discipline, what is examinee’s prognosis?

Within the scope of your medical discipline, what are the present medicals barriers to the examinees recovery, if any?

Within the scope of your medical discipline, is the examinee able to resume full-time work at this time? If not, when will the examinee be capable of doing so?

Within the scope of your medical discipline, what are the examinees present physical restrictions, if any? And how are those restrictions being addressed by way of treatment?

Within the scope of your medical discipline, is the examinee capable of graduated return to work at this time? If not, when will the examinee be able to do so? If applicable, please detail the graduated return to work plan.

Within the scope of your medical discipline, does the examinee require medication?

Within the scope of your medical discipline, please comment on the reasonableness of the examinees current treatment as to benefit & therapeutic value.

Within the scope of your medical discipline, does the premorbid medical history suggest that the examinee would have exhibited physical restrictions that would have limited his/her functional abilities prior to your examination?

Within the scope of your medical discipline, do you suspect any abnormal underlying pathology requiring further medical investigation? If yes, please explain.

Within the scope of your medical discipline, has maximum medical recovery (MMR) been achieved? If not please indicate an anticipated time frame. If MMR has been reached, please provide an explanation for concluding that the condition is stable and stationary and unlikely to change.

Within the scope of your medical discipline, do you recommend any further treatment / assistive devices to reduce and/or eliminate these restrictions? If so, please indicate type & frequency.

Within the scope of your medical discipline, are there any further considerations or recommendations you might suggest in order to enhance this individual’s return to maximum functioning?

Within the scope of your medical discipline, what is the present psychological status with the resulting DSM IV code? Is this permanent or temporary?

Within the scope of your medical discipline, do your objective findings indicate any cognitive deficits as a result of the accident? If yes, please indicate the estimated duration of impairment.

Within the scope of your medical discipline, are the examinees cognitive abilities intact and is there normal thought process present? Please comment.

Within the scope of your medical discipline, do you consider the rate of progress to be satisfactory in this case?

Within the scope of your medical discipline, is further medical investigation required? If so, what investigations and why?

Within the scope of your medical discipline, has the examinee been following the recommended treatment protocol prior to your examination?

Within the scope of your medical discipline, is anything impeding further or a more timely recovery?

Please indicate if there are any non-medical barriers which have or are preventing a return to gainful employment.

Within the scope of your medical discipline, is the examinee able to resume full-time work at this time? If not, when will the examinee be capable of doing so? If applicable, please detail the graduated return to work plan.

Please indicate if there are any non-medical barriers which have or are preventing a return to gainful employment.

Your opinion regarding the examinee’s ability to perform any occupation for which he/she has the minimum qualifications. If an alternative occupational role has been offered please specify

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Employer Referral Form

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Employer Information

Examinee Treating Physician

Type of Assessment

Additional Services To Be Arranged AssessMed

Final Report / Special Instructions

Optional Referral Questions

Make a Referral

Administrative Opportunites

Medical Opportunites

Quality assessments - timely reporting

Employer Referral Form

Evaluee

Employer Information

Examinee Treating Physician

Type of Assessment

Additional Services To Be Arranged AssessMed

Final Report / Special Instructions

Optional Referral Questions

Make a Referral

Administrative Opportunites

Medical Opportunites

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