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IME Charges Protocol (Effective 11/15/2016) Page 1 of 2 Billing & Scheduling Contact: Spine Consultants 1300 Higgins Road Suite 200 Park Ridge, IL 60068 7733212800 Fax: 7733212801 Contact: Workers

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Begin by providing your personal information, such as your name, contact details, and address.

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Proceed to fill out the relevant sections regarding the charges for the IME (Independent Medical Examination). This may include details about the healthcare provider, dates, and procedures involved.

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Insurance companies might require this form when assessing the charges and expenses related to an independent medical examination.

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Legal professionals, such as attorneys or paralegals, may need this form to accurately record and present the IME charges as part of their case.

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Claimants or individuals undergoing an independent medical examination may also need to complete this form as part of the process.

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