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REQUEST FOR MEDICAL EVALUATION Please FAX to 857-368-0802 and mail original to: Medical Affairs, P.O. Box 55889, Boston, MA 02205 This form is used to report a person you believe is no longer physically

How to fill out request for medical evaluation

How to fill out a request for a medical evaluation:

1. Start by gathering all the necessary information. This includes the patient's full name, contact details, birthdate, and any relevant identification numbers (such as social security or insurance numbers).
2. Next, specify the reason for the medical evaluation. Clearly state the symptoms or condition that require evaluation, providing as much detail as possible. If there are any specific concerns or questions for the evaluating physician, make sure to include them as well.
3. Indicate the preferred date and time for the evaluation. If there is flexibility, it is helpful to include alternative options. Note that the availability of specific dates may depend on the healthcare provider or facility.
4. Provide information about the referring physician or healthcare professional, including their name, contact information, and any appropriate credentials. If there are any specific instructions or reports that should be forwarded along with the request, mention them in this section too.
5. If applicable, include any relevant medical history or records that may aid the evaluating physician in understanding the patient's condition. This can include recent test results, imaging scans, or previous medical reports.

Who needs a request for medical evaluation?

1. Individuals who are experiencing unexplained symptoms or conditions that require a professional medical assessment may need a request for a medical evaluation. This can include issues such as persistent pain, neurological disorders, respiratory problems, or mental health concerns.
2. Patients who have been referred to a specific specialist or healthcare facility for further evaluation or consultation may also require a formal request. This is often the case when the referring physician wants the evaluating physician to focus on specific aspects or conduct specialized tests.
3. In some cases, employers or insurance companies may request a medical evaluation for employees. This can occur for purposes such as determining fitness for work, assessing disability claims, or reviewing medical clearance for certain job roles.

By following these guidelines, individuals can ensure that their request for a medical evaluation is properly completed and provides the necessary information for the evaluating physician to make an accurate assessment.

For pdfFiller’s FAQs

What is request for medical evaluation?

Request for medical evaluation is a formal document submitted to request an assessment of a person's physical or mental health by a medical professional.

Who is required to file request for medical evaluation?

The request for medical evaluation can be filed by employers, employees, insurers, or other parties involved in a workers' compensation case.

How to fill out request for medical evaluation?

To fill out a request for medical evaluation, one must provide information about the injured party, the nature of the injury or illness, and any relevant medical history.

What is the purpose of request for medical evaluation?

The purpose of the request for medical evaluation is to obtain an independent assessment of the injured party's medical condition and any potential impact on their ability to work.

What information must be reported on request for medical evaluation?

The request for medical evaluation must include details such as the injured party's name, contact information, date of injury, description of the injury, and any previous medical treatment received.

How do I make changes in request for medical evaluation?

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