Life and Health Benefits

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Injuries (Please include all details):

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Independent Examinations - Assessment Type

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Please select from the following listing of services and disciplines. If there is a service or discipline not otherwise indicated, please use the "other specialty/expertise" text box to type in your request or call us at 1.866.432.7211, fax us at 519.432.7522 or email us.

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Executive Summary

Referral Questions

Attach File

Neuropsychological Assessment (Check all that apply)

Current symptoms and diagnosis based on your test results.

Use -Expected course and long term prognosis.

Use -What are the specific cognitive complaints the claimant reported? Are these complaints consistent with the claimant's test results?

Use -Are the claimant's complaints and test results consistent with a focal lesion or any other type of specific organic brain injury?

Use -Could psychiatric/psychological factors alone explain the claimant's symptom picture?

Use -Can alternate hypotheses be eliminated?

Use -Is there any evidence on inconsistent effort or extreme scores which suggest cognitive functioning which is worse than that found in those with severe brain injuries? What type of symptom validity testing was done and what were the results?

Use - Q8. In your view, does he/she suffer from cognitive deficits which prevent him/ her from initiating a graduated return to his/her previous employment (based on the enclosed job description) on full-time or part-time basis?
- If no, please provide a specific date on which he/ she could begin a return to work. In addition, please specify exactly the days and hours that he/ she could start with and the exact number of weeks he/ she will require to reach full-time hours, noting a specific date on which he/ she would be able to resume full-time hours.
- If yes, please indicate which condition or combination of conditions are disabling, and any restrictions associated with that condition(s).

Use -In your view, does the claimant suffer from sufficient cognitive impairment which prevents him/her from returning to any type of alternate employment on a part-time or full-time basis commensurate with his or her skills and abilities?
- If no, please provide a specific date on which he/ she could begin working with an alternate employer, as well as a specific date by which he/ she would be able to resume full-time hours. Please note any restrictions which would apply to alternate employment and how long they would be in place.
- If yes, please indicate which condition or combination of conditions is disabling, and exactly what the claimant’s current restrictions are as a result of that condition(s).

Use -If the claimant is currently not capable of resuming any form of employment, as of what date could he/ she reasonably be expected to initiate a graduate RTW schedule? Please indicate if you expect that he/ she will never be able to resume full-time employment, and the maximum hours you would expect in the long term.

Use -Please provide any treatment recommendations with regard to intervention, counseling, and/or medication. In your view, is the claimant’s current treatment appropriate and sufficient? Is intervention from a psychologist required at this time?

Use -If you deem any further investigation or testing is required, please provide a recommendation as to the specialist you would regard as most suitable to perform it.

FAE (Check all that apply)

Current symptoms and subjective tolerances.

Use -Current restrictions and/or limitations. Please provide tolerances for sitting, standing, walking, lifting, keyboarding, etc. per instance and total for the day.

Use -In your view, based on the FAE, is the claimant capable of returning to his/her former job duties?
- If yes, please provide a specific date on which he/ she could begin working and the initial number of days and hours, as well as a specific date on which he/ she could resume her former hours.
- If no, please indicate exactly what the claimant’s current restrictions are as a result of that condition(s).

Use -In your view, based on the FAE, does he/ she have any restriction/limitations which prevent him/her from returning to any type of employment on a part-time or full-time basis commensurate with her current capacities at a sedentary light level?
- If no, please provide a specific date on which he/ she could begin working with an employer, and the initial number of days and hours, as well as a specific date by which would be able to reach full hours. Please note any restrictions which would apply to alternate employment.
- If yes, please indicate the current limitations/restrictions which prevent him/ her from returning to any type of employment.

Use -If the claimant is currently not capable of resuming any form of employment, when could reasonably he or she be expected (earliest and latest date) to initiate a graduated RTW schedule?

Psychiatric IME (Check all that apply)

Current symptoms and diagnosis. What is the DSM-IV and GAF classification? Is there a basis for an AXIS II diagnosis?

Use -Current restrictions and/or limitations due to psychiatric factors.

Use -Overall, what is his/her expected course and long term prognosis?

Use -In your view, are the claimant’s ongoing problems with progressing to a GTRW solely or primarily related to the claimant’s problems and concerns related to his/her current employer, co-worker/supervisor conflicts, performance problems, and/or a dislike for her job duties, work hours or work site location?

Use -In your view, based on the results of your examination, is the claimant capable of returning to work on a part-time or full-time basis?
- If yes,please provide a specific date on which the claimant could begin a return to work. In addition, please specify exactly the days and hours that the claimant could start with and the exact number of weeks he/she will require to reach full-time hours, noting a specific date on which he/she would be able to resume full-time hours.
- If no, please indicate which condition or combination of conditions are disabling and exactly what the claimant's current restrictions are as a result of that condition(s).

Use -In your view, does he/she suffer from a psychiatric condition which prevents he/she from returning to any type of alternate employment on a part-time or full-time basis commensurate with he/she's skills and abilities?
- If no, please provide a specific date on which the claimant could begin working with an alternate employer, as well as a specific date by which the claimant would be able to resume full-time hours. Please note any restrictions which would apply to alternate employment and how long they would be in place.
- If yes, please indicate which condition or combination of conditions are disabling and exactly what the claimant’s current restrictions are as a result of that condition(s).

Use -If the claimant is currently not capable of resuming any form of employment, as of what date could he/she reasonably be expected to initiate a graduated RTW schedule. Please indicate if you expect that he/she will never be able to resume full-time employment and the maximum hours you would expect in the long term.

Use - Q8. Please provide any treatment recommendations with regard to intervention, counseling, and/or medication. In your view, is the claimant’s current treatment appropriate and sufficient?

Use -If you deem any further investigation or testing is required, please provide a recommendation as to the specialist you would regard as most suitable to perform it.

Physical IME Physiatry, Orthopedic, Etc. (Check all that apply)

Current symptoms and diagnosis.

Use -Current restrictions and/or limitations due to physical factors.

Use -Overall, what is the claimant’s expected course and long term prognosis?

Use -In your view, are the claimant’s ongoing problems with progressing to a GTRW solely or primarily related to the claimant’s problems and concerns related to his/her current employer, co-worker/supervisor conflicts, performance problems, and/or a dislike for her job duties, work hours or work site location?

Use -In your view, based on the results of your examination, is the claimant capable of returning to work on a part-time or full-time basis?
- If yes, please provide a specific date on which the claimant could begin to work. In addition, please specify exactly the days and hours that the claimant could start with and the exact number of weeks the claimant would be able to resume full-time work.
- If no, please indicate which condition or combination of conditions are disabling and exactly what the claimant’s current restrictions are as a result of that condition(s).

Use -In your view, does the claimant suffer from a physical condition which prevents he/she from returning to any type of alternate employment on a part-time or full-time basis commensurate with the claimant’s skills and abilities?
- If no, please provide a specific date on which the claimant could begin working with an alternate employer, as well as a specific date by which the claimant would be able to resume full-time hours. Please note any restrictions which would apply to alternate employment and how long they would be in place.
- If yes , please indicate which condition or combination of conditions are disabling and exactly what the claimant’s current restrictions are as a result of that condition(s).

Use -If the claimant is currently not capable of resuming any form of employment, as of what date could the claimant reasonably be expected to initiate a graduated RTW schedule? Please indicate if you expect that the claimant will never be able to resume full-time employment and the maximum hours you would expect in the long term.

Use -Please provide any treatment recommendations with regard to intervention and/or medication. In your view, is the claimant’s current treatment appropriate and sufficient?

Use -If you deem any further investigation or testing is required, please provide a recommendation as to the specialist you would regard as most suitable to perform it.

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