Parthenia Medical Group
Parthenia Medical Group

 

Requestor Information
 * required fields
* Referal Source:
Firm Name
 * First Name
 * Last Name
 Title
* Mailing Address
 * City
 * State
 * Zip
* Phone Number
 * Email

Billing Information
Same as Requestor: (if different, all fields are required.)
Carrier/Employer/Govt. Agency/Other
 Claims Examiner
Mailing Address
 City
 State
 Zip
Phone Number
 Email
return to top

Physician Request
Specialty
 Physician
Preferred date of Exam (upon physician availability)
First available date     From:  / /     To:  / /
City where claimant resides
 Office Location
Would you like us to send an appointment letter?  yes no
Is there a decision date?  yes no Date: / /
Do you need a same day status sheet?  yes no
Do you need a completed report by a certain date?  yes no
Date: / /  Reason:
Will you be sending medical records, personnel records, etc? yes no
Would you like records: returned destroyed
return to top | previous

Claimant Information
* Last Name
 * First Name
 M.I.
 Title
Mailing Address
 City
 State
 Zip
Home Phone
 Message Phone
 Cell Phone/Pager
Dates of Injury(ies)

1. / / Specific or CT?     Claim Number:

End date: / /

2. / / Specific or CT?     Claim Number:

End date: / /

3. / / Specific or CT?     Claim Number:

End date: / /
Part(s) of body injured:

1.   2.   3.

Employer at time of Injury:

Has Claim Been Denied? yes no
Is Claim Litigated? yes no

Is this a:
new evaluation
reevaluation
request to reschedule
schedule previously failed appointment

Type of evaluation requested:
Date of Birth
/ / 		Social Security Number
/ /
Does claimant need interpreter?  yes no

PMG to arrange Interpreter: (In California only)
Referrer to arrange:

Language:
Same as Requestor: (if different, all fields are required.)

Defense Attorney Name
Phone
Fax
Mailing Address
City
State
Zip
Email
Secretary
Extension
Same as Requestor: (if different, please fill in all fields.)

Claimant/Plaintiff/Applicant Attorney
Phone
Fax
Mailing Address
City
State
Zip
Email
Secretary
Extension
Special Request / Comments / Additional Physicians & Medical Specialties required

  
return to top | previous

Submitting this form does not constitute a confirmed appointment. Confirmation will be made by telephone, email or fax from Parthenia Medical Group, Inc.

Please send all records, x-rays, and cover letter
at least seven days before exam to:

Parthenia Medical Group, Inc.
8660 Woodley Avenue
North Hills, CA 91343

home | contact | search | services | medical specialties | locations | scheduling
© 2009 Parthenia Medical Group, Inc. Disclaimer & Privacy Statement

home contact