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Referral

Let the Industry Experts Handle Your Medical Assessment Needs

Elite Experts promises the same exceptional customer service delivery throughout each step of the IME process. Whether you submit your request by phone, fax, email or online, we are committed to being responsive, providing our clients with a truly seamless and consistent experience.

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Referral Form

Step 1 of 3

33%

EXAMINEE INFORMATION
Salutation:
First Name:
Last Name:
Address Address 2 City Province Postal Code
Telephone:
Cell Phone:
Email:
Date of Loss:
MM slash DD slash YYYY

REFERRAL SOURCE
Referral Contact:
Company Name:
Address Address 2 City Province Postal Code
Telephone:
Cell Phone:
Email:
Fax:
Referral Type:
- Accident benefits
- Bodily Injury
- Medlegal-Plaintiff
- Medlegal-Defense
- STD/LTD
Reference Number:
Claim Number:*
Policy Number:*
File Number:*
Alternate Contact Name:
Alternate Telephone:
Alternate Email:
Insurance Company:
Insured’s Name:
Policy Number:

ASSESSMENTS REQUESTED
Reason for Assessment:
Other Services Requested:
- Interpreter
- Transportation
- Travel/Accommodation
Interpreter:
- Yes
- No
Language:
Transportation:
- Yes
- No
*
- Same as address above:
Transportation Address:*
Address 2 City Province Postal Code
Accommodation Required:
- Yes
- No
Communication Requirements
- Email
- Fax
Referral Source Assessment Confirmation to be sent by:
- Email
- Fax
- Other
Other:
Examinee Notice of Assessment Required
- Yes
- No
If Yes, and CC required?
OTHER COMMENTS / SPECIAL INSTRUCTIONS

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Get In Touch!

4838 Richard Road SW, Suite 300
Calgary, AB T3E 6L1
1(403) 407-1870
1(403) 407-5884
inquiries@eliteexperts.ca
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Business hours

Monday - Friday: 9 AM – 6 PM
Saturday - Sunday: By request
Emergency Service: 24/7

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