Skip to content

847-470-8740
Home
Appointments
Conditions
Treatments
Blog
Location
- Des Plaines
Schedule IME

Search for:

IME Scheduling FormMichael Zorko2024-02-19T10:57:26-06:00

IME & Impairment Rating Scheduling Form

Thank you for using the IME/Impairment Rating Scheduling Form. Once completed, you will receive an email confirmation that we received the request. We will contact you in the next business day to confirm your appointment date.

Step 1 of 4

25%

Patient Information
Patient Name
First Last
Date Of Birth
MM slash DD slash YYYY
SS#
Patient Phone
Patient Mobile
Patient Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Case Information
Claim Number
Date Of Injury
MM slash DD slash YYYY
Body Part Treated
Employer
Appointment Requested
- IME
- IME + Drug test
- IME & Impairment Rating
Choose Location
- CPMG Des Plaines | 2750 S. River Rd. 1st Floor - Des Plaines, IL 60018
Note: Dr. Konowitz is at the Wisconsin locations on the 3rd Friday of every month.

Workers' Compensation Information
Carrier/Billing Information
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Adjuster
Adjuster Name
First Last
Adjuster Phone Number
Adjuster Fax Number
Adjuster Email
Case Manager
Case Manager
First Last
Case Manager Phone
Case Manager Fax
Case Manager Email
Would you like to enter Attorney Information for either the Plaintiff or the Defense?
- Yes
- No

Attorney Information: Plaintiff
Attorney Name | Plaintiff
First Last
Law Office/Firm
Plaintiff Attorney Phone
Plaintiff Attorney Fax
Plaintiff Attorney Email
Attorney Information: Defense
Attorney Name | Defense
First Last
Law Office/Firm
Defense Attorney Phone
Defense Attorney Fax
Defense Attorney Email

Scheduler Information
The person completing this request is the:
- Adjuster
- Case Manager
- Plaintiff Attorney
- Defense Attorney
- Scheduler
Scheduler Name
First Last
Scheduler Email
Please send a copy of the report to the following:
- Employer
- Adjuster/IME Company
- Case Manager
- Insurance Company
- Plaintiff Attorney
- Defense Attorney
Additional Comments
File Upload (PDF Only)
Drop files here or

Accepted file types: pdf, Max. file size: 100 MB.
Complete
Thank you for using our online appointment request form. A copy of this request will be emailed to you upon submission. The information you provided will be viewed by our Workers' Compensation Department. Someone will contact you shortly with a date and time for the scheduled appointment.

Info We Collect

Patient Information
Case Information
Billing Information
Adjuster/Case Manager Information
Attorney Information
Scheduler Information
Contact Information
Records Upload Option
Additional Information

Portal Menu

IME INFORMATION FORM

SECURE FILE UPLOAD

IME/IMPAIRMENT RATING POLICY

CPMG FAST FACTS

Comprehensive Pain Management Group | Copyright ©

Toggle Sliding Bar Area