Illinois Bone and Joint Institute - Office LocatorIllinois Bone and Joint Institute - Our PhysiciansIllinois Bone and Joint Institute - Scope of ServicesIllinois Bone and Joint Institute - Patient Information
  Scope of Services   IME Appointment tool

All Services:
Arthritis (Osteo and Rheumatoid)
Arthroscopy
Autoimmune Diseases
Foot & Ankle (Also see Pain-Arthritic)
Fracture Care - Trauma
General Orthopaedic
Hand & Upper Extremity (Also see Pain-Arthritic)
Hips (Also see Pain-Arthritic)
IME
Joint Reconstructive Surgery
Knees (Also see Pain-Arthritic)
Lupus and Related Diseases
MRI & Other Diagnostics
Orthopaedic Oncology
Osteoporosis
Pain - Arthritic
Pain Management
Pediatric Orthopaedic
Pediatric Rheumatology/Arthritis
Physical & Occupational Therapy
Podiatry
Rheumatology
Shoulders (Also see Pain-Arthritic)
Spine (Also see Pain-Arthritic)
Sports Medicine
Total Joint Replacement
Workers Compensation

IME Online Appointment Request Form

IME scheduling department
877-385-8755
Fax: 847-929-1127
Pager: 847-569-8523
e-mail:ibjiime@ibji.com

ALL FIELDS MARKED WITH A * MUST BE COMPLETED IN ORDER TO SUBMIT FORM

IME requested by:*
E-mail:*
Fax:
Phone:*
NOTE: OUR RESPONSE TO YOU CONCERNING THIS APPOINTMENT REQUEST WILL BE VIA EMAIL.
Send bills & report to:
Name:*
E-mail:
Company:*
Phone:*
Fax:*
Address:*
City:*
State:*
Zip:*
Also send report to:
Name:
E-mail:
Company:
Phone:
Fax:
Address:
City:
State:
Zip:
Name:
E-mail:
Company:
Phone:
Fax:
Address:
City:
State:
Zip:
Type of IME:*
Current Treating Physician:
Specific IBJI Provider requested?*
No Yes
If Yes, then:
Requested Physician:
Indicate Location Preference:
No Location Preference Prefer Location Near Zip Code
When would you prefer the appointment be scheduled?
within 3-7 days within 8-13 days within 14-21 days Other
Is the patient bringing films?
No Yes
Is the physician authorized to take x-rays?
No Yes Call this number for Authorization
Is the physician authorized to order MRI/CT scan?
No Yes Call this number for Authorization
Patient Name:*
Date of Birth:*
Social Security #:
Date of Injury:*
Claim #:*
Body Part:*
      Foot Right Left Bilateral
      Ankle Right Left Bilateral
      Leg Right Left Bilateral
      Knee Right Left Bilateral
      Hips Right Left Bilateral
       Arm Right Left Bilateral
      Shoulder Right Left Bilateral
Spine      
Neck      
Wound Care      
Rheumatology      
Other (specify>):
 
Home Address:*
City:*
State:*
Zip:*
Home Phone:
Work Phone:
E-mail:
Does the Patient speak English?*
Yes No (If no, an interpreter must accompany the patient.)
Employer
Employer Address:
City:
State:
Zip:

This online request for an IME appointment will be received by IBJI's IME staff within one business day. You will be contacted via email with information about the appointment, the physician's IME protocols and our charges. Please feel free to contact us at the phone number at the top of this form if you wish.

NOTE THAT MEDICAL RECORDS SHOULD BE RECEIVED BY THE PHYSICIAN ONE WEEK PRIOR TO THE APPOINTMENT.

Other information for physician:
   
   

 

Home | Office Locator | Our Physicians | Scope of Services | Patient Information | Career Opportunities

© 2003 Illinois Bone & Joint Institute