Form Test Page

Service Order Request

Thanks for coming to our website to order your service. Please note that any fields with a red asterisk (*) must be filled out in order to move to the next page of the request form. We appreciate your business!
First Name*
Last Name*
Company*
Address
City
State
Zip Code
Phone Number*
Fax Number
Email Address*
Please select one:*
- I am the person handling this claim and I am requesting this service.
- I am requesting this service on the behalf of another person. (ie. Paralegal ordering for attorney)
What is your role in this service request?*
Other:
Please let us know who you are requesting this service on behalf of (ie. attorney or adjuster name):
First Name*
Middle Name/Initial
Last Name*
Company*
Address
City
State
Zip Code
Phone Number*
Fax Number
Email Address*
State of Jurisdiction:*
Other:*

Please enter state name.
Type of Claim:*
Type of Claim:*
Type of Claim:*
Type of Claim:*
Other:*
Service type you are requesting:*
Service type you are requesting:*
Service type you are requesting:*
Service type you are requesting:*
Time Frame Needed:*
Please let us know your required time frame. If you have deadlines, please let us know here.*
Length of phone conference you are requesting:*
If other, please explain:*
Trial Block Dates*
Date(s) you request the doctor be available:*
Requesting Full or Half Day Testimony:*
County and State where Trial will take place:*
Courthouse Address*
Street Address Address Line 2 City State ZIP Code
Specialty of doctor you are requesting:*
If other, let us know what you are looking for:*
Contact me:
- Please contact me with doctor, date, and time options prior to scheduling.
If you choose this option, we will contact you with doctor, date and time options prior to officially arranging the service. You can then tell us which option you would like to proceed with. Otherwise, we will just schedule the service based on the parameters you have selected and send you notice.
Specific Doctor/Specialist Request: (Please enter their name here.)
Enter doctor name here:*
Please provide us with claimant information. Any fields that have an asterisk are required fields. If you plan to have Woodlake send notices, please be sure to fill in all the address information. If we are not sending notices, only the city and state are required.
Please provide us with claimant information. Any fields that have an asterisk are required fields.
Claimant First Name*
Claimant Middle Name or Initial
Claimant Last Name*
Claimant Birthdate*
Claimant Gender*
- Female
- Male
If claimant is a minor, please provide guardian first and last name:
Claimant Street Address:

Be sure to include apartment number if applicable.
City*
State:*
Zip Code:
Claimant Street Address:*

Be sure to include apartment number if applicable.
City*
State:*
Zip Code:*
If you plan to have Woodlake make follow-up calls to verify receipt of notice and/or reminder calls prior to the IME, please include as many phone numbers as possible. Thank you!
Home Phone Number
Cell Phone Number
Work Phone Number
Claimant Email Address
Will the claimant need an interpreter for this evaluation?*
- Yes
- No
- Unknown
Type of interpreter needed:*
- Spanish
- Somali
- Karen
- Hmong
- ASL - American Sign Language
Date of Loss:*
Claim/File Number:*
Is this service being scheduled for more than one date of loss?*
- Yes
- No
If more than one date of loss, how many?
- 2
- 3
- 4
- 5
- 6
2nd Date of Loss:*
Claim Number for 2nd Date of Loss:*
3rd Date of Loss:*
Claim Number for 3rd Date of Loss:*
4th Date of Loss:*
Claim Number for 4th Date of Loss:*
5th Date of Loss:*
Claim Number for 5th Date of Loss:*
6th Date of Loss:*
Claim Number for 6th Date of Loss:*
Is this claim currently in litigation?*
- Yes
- No
Please provide the legal case name:*
Please provide the legal case name:*
Please provide the court case number, if available:
Please provide the court case number, if available:
Body Part(s) to be addressed:*
- Head - Headaches
- Head - Cognitive Issues
- Head - TBI (Traumatic Brain Injury)
- Head - PTSD (Posttraumatic Stress Disorder)
- Head - Depression
- Head - Concussion
- Eye - Left
- Eye - Right
- Eye - Bilateral
- Ear - Left
- Ear - Right
- Ear - Bilateral
- Ear - Left Hearing Loss
- Ear - Right Hearing Loss
- Ear - Bilateral Hearing Loss
- Nose
- Sinus
- Mouth
- Lip - Upper
- Lip - Lower
- Tongue
- Teeth
- Chin
- Jaw
- Jaw - TMJ (Temporomandibular Joint Disorder)
- Spine - Cervical - Neck Non-Surgical
- Spine - Cervical - Neck Surgical
- Arm - Left Radicular Pain
- Arm - Right Radicular Pain
- Arm - Bilateral Radicular Pain
- Shoulder - Left Non-Surgical
- Shoulder - Right Non-Surgical
- Shoulder - Bilateral Non-Surgical
- Shoulder - Left Surgical
- Shoulder - Right Surgical
- Shoulder - Bilateral Surgical
- Bicep - Left
- Bicep - Right
- Bicep - Bilateral
- Elbow - Left Non-Surgical
- Elbow - Right Non-Surgical
- Elbow - Bilateral Non-Surgical
- Elbow - Left Surgical
- Elbow - Right Surgical
- Elbow - Bilateral Surgical
- Elbow - Left CTS (Cubital Tunnel Syndrome)
- Elbow - Right CTS (Cubital Tunnel Syndrome)
- Elbow - Bilateral CTS (Cubital Tunnel Syndrome)
- Forearm - Left
- Forearm - Right
- Forearm - Bilateral
- Wrist - Left Non-Surgical
- Wrist - Right Non-Surgical
- Wrist - Bilateral Non-Surgical
- Wrist - Left Surgical
- Wrist - Right Surgical
- Wrist - Bilateral Surgical
- Wrist - Left CTS (Carpal Tunnel Syndrome)
- Wrist - Right CTS (Carpal Tunnel Syndrome)
- Wrist - Bilateral CTS (Carpal Tunnel Syndrome)
- Hand - Left
- Hand - Right
- Hand - Bilateral
- Finger - Left Thumb
- Finger - Right Thumb
- Finger - Bilateral Thumb
- Finger - Left Index
- Finger - Right Index
- Finger - Bilateral Index
- Finger - Left Middle
- Finger - Right Middle
- Finger - Bilateral Middle
- Finger - Left Ring
- Finger - Right Ring
- Finger - Bilateral Ring
- Finger - Left Pinky
- Finger - Right Pinky
- Finger - Bilateral Pinky
- Spine - Thoracic - Mid Back Non-Surgical
- Spine - Thoracic - Mid Back Surgical
- Spine - Cervical, Thoracic, & Lumbar - Non-Surgical
- Rib(s) - Left
- Rib(s) - Right
- Rib(s) - Bilateral
- Lung - Left
- Lung - Right
- Lung - Bilateral
- Heart
- Kidney - Left
- Kidney - Right
- Kidney - Bilateral
- Liver
- Pancreas
- Bladder
- Hernia
- Hernia - Umbilical
- Hernia - Inguinal
- Hernia - Incisional
- Hernia - Femoral
- Hernia - Hiatal
- Spine - Lumbar - Low Back Non-Surgical
- Spine - Lumbar - Low Back Surgical
- Hip - Left Non-Surgical
- Hip - Right Non-Surgical
- Hip - Bilateral Non-Surgical
- Hip - Left Surgical
- Hip - Right Surgical
- Hip - Bilateral Surgical
- Groin - Left
- Groin - Right
- Groin - Bilateral
- Leg - Left Radicular Pain
- Leg - Right Radicular Pain
- Leg - Bilateral Radicular Pain
- Knee - Left Non-Surgical
- Knee - Right Non-Surgical
- Knee - Bilateral Non-Surgical
- Knee - Left Surgical
- Knee - Right Surgical
- Knee - Bilateral Surgical
- Shin - Left
- Shin - Right
- Shin - Bilateral
- Ankle - Left Non-Surgical
- Ankle - Right Non-Surgical
- Ankle - Bilateral Non-Surgical
- Ankle - Left Surgical
- Ankle - Right Surgical
- Ankle - Bilateral Surgical
- Foot - Left
- Foot - Right
- Foot - Bilateral
- Toe - Left Big
- Toe - Right Big
- Toe - Bilateral Big
- Toe - Left 2nd
- Toe - Right 2nd
- Toe - Bilateral 2nd
- Toe - Left 3rd
- Toe - Right 3rd
- Toe - Bilateral 3rd
- Toe - Left 4th
- Toe - Right 4th
- Toe - Bilateral 4th
- Toe - Left Little
- Toe - Right Little
- Toe - Bilateral Little
- Skin - Dermatitis
- Skin - Cancer
- Skin - Burn(s)
- Skin - Laceration(s)
- Skin - Dog Bite
- Skin - Allergic Reaction
- Skin - Other
- RSD - Reflex Sympathetic Dystrophy
- CRPS - Complex Regional Pain Syndrome
- Allergic Reaction - Allergies
- OTHER
- OTHER
- OTHER
- OTHER
- OTHER
- OTHER
- OTHER
- OTHER
- OTHER
Begin to type the body part and a list will appear to provide you options. You can select one body part and then repeat the process if more than one body part will need to be addressed. If you accidentally select a wrong part, just click on the blue check mark to remove that body part from the list.
Employer Company Name*
Pension Fund Name*
Occupation
Is this an accepted claim?*
- Yes
- No
Does the claimant have legal representation?*
- Yes
- No
Please provide us with the claimant's attorney information. Required fields include an asterick.
Claimant's Attorney First Name*
Claimant's Attorney Middle Name or Initial
Claimant's Attorney Last Name*
Claimant's Attorney Firm Name*
If you plan to have Woodlake send notices to the attorney or place reminder calls, please be sure to fill in the address and/or phone information below. Thank You.
Claimant's Attorney Street Address
Claimant's Attorney City
Claimant's Attorney State Abbreviation
Claimant's Attorney Zip Code
Claimant's Attorney Phone Number
Claimant's Attorney Fax Number
Please enter any special notes regarding the claimant's attorney contact here:
Almost there! Just need to collect a few more details about which services you would like us perform.
Would you like Woodlake to direct schedule with the claimant and/or their attorney?*
- Yes - Please make up to three call attempts to verify a location, date, and time that will work for the claimant.
- No - Please just schedule a date and time as specified
Would you like Woodlake to send notification of the evaluation?*
- Yes
- No
Who would you like Woodlake to send notices to?*
- To the claimant's attorney only.
- To the claimant and their attorney.
Would you like Woodlake to perform a reminder call?*
- Yes
- No
Would you like Woodlake to send a mileage check for this service?*
- Yes
- No
If Woodlake sends a mileage check, you will be invoiced for the mileage upon completion of the service.
Send the mileage check to:*
- Claimant
- Claimant's Attorney
Does the doctor have permission to obtain x-rays as part of the service?*
- Yes
- No
- Call for approval
Would you like Woodlake to obtain imaging studies found in the medical records?*
- Yes
- No
- No, I will obtain imaging to send to Woodlake.
- Per case basis. Please contact me with a list of studies that are needed. I will approve/decline at that time.
- Please only obtain them if the doctor has indicated they must have imaging studies to complete the service I am requesting.
The fee for this service is $50 per provider and any incidental costs (ie. copy fees, shipping).
What is your cover letter preference?*
- I will write and submit the cover letter.
- Defense counsel will submit the cover letter.
- I would like Woodlake to create a cover letter for me to approve.
What is your cover letter preference?*
- I will write and submit the cover letter.
- Defense counsel will submit the cover letter.
- I would like Woodlake to create a cover letter for me to approve.
What is your cover letter preference?*
- I will write and submit the cover letter.
- Defense counsel will submit the cover letter.
- I would like Woodlake to create a cover letter for me to approve.
- I would like to use the check off form as my cover letter.
Please let us know what your main concern is with regard to this service request. This will help with specialist/doctor selection, if necessary, and the QA process. If you have requested a cover letter be written, it will also aid in producing appropriate questions to ensure the doctor focuses on your area of concern. Any additional information regarding the injury or claim can also be entered here. Click "Other" to leave us a note with regard to anything unusual we should be aware of while handling this service. Thank You.
Concerns to be addressed for this service:*
- Diagnosis
- Causation
- Ongoing Treatment
- Past Treatment - Appropriate/Related
- Maximum Benefit/Maximum Medical Improvement
- Further Treatment
- Work Ability
- PPD Rating (Workers' Compensation)
- Other (Or mark if you have additional information we should be aware of for this service request.)
Other concerns to be addressed for this service or addtional information you need to inform us of:*
Please let us know which questions you would like the doctor to address as part of this service:
- What injuries were sustained in the accident in question and what is the current status of those injuries?
- Have all treatment and diagnostic studies been reasonable and necessary for injuries sustained in the accident(s)? If not, please specify what has not been reasonable and necessary, and why.
- Has the claimant reached maximum benefit from medical care, chiropractic care, and/or physical therapy treatment relative to any injuries sustained in the accident in question?
- Is any additional treatment necessary relative to any injuries sustained in the accident in question? If so, please specify the type, frequency, and duration of that care.
- Are any additional ancillary or diagnostic studies required relative to any injuries sustained in the accident in question? If so, please explain.
- Is the claimant capable of working relative to any injuries sustained in the accident in question? If only with restrictions, please specify those restrictions, describing particular physical limitations (i.e. lifting, pushing, pulling etc.), and comment on the expected duration of the restrictions.
- Is the claimant capable of performing activities of daily living relative to any injuries sustained in the accident in question? If only with restrictions, please specify those restrictions and comment on the expected duration of the restrictions.
- Please indicate the amount of time spent with the claimant during the examination.
- Additional Questions or Concerns (Please be very specific in the box below.):
MN PIP IME
Please let us know which questions you would like the doctor to address as part of this service:
- What injuries were sustained in the accident in question and what is the current status of those injuries?
- Have all treatment and diagnostic studies been reasonable and necessary for injuries sustained in the accident(s)? If not, please specify what has not been reasonable and necessary, and why.
- Has the claimant reached maximum benefit from medical care, chiropractic care, and/or physical therapy treatment relative to any injuries sustained in the accident in question?
- Is any additional treatment necessary relative to any injuries sustained in the accident in question? If so, please specify the type, frequency, and duration of that care.
- Are any additional ancillary or diagnostic studies required relative to any injuries sustained in the accident in question? If so, please explain.
- Is the claimant capable of working relative to any injuries sustained in the accident in question? If only with restrictions, please specify those restrictions, describing particular physical limitations (i.e. lifting, pushing, pulling etc.), and comment on the expected duration of the restrictions.
- Is the claimant capable of performing activities of daily living relative to any injuries sustained in the accident in question? If only with restrictions, please specify those restrictions and comment on the expected duration of the restrictions.
- Additional Questions or Concerns (Please be very specific in the box below.):
MN PIP IMRR
MN PIP Additional Questions*
MN PIP Additional Questions
Please let us know which questions you would like the doctor to address as part of this service:
- The diagnosis and cause of the current condition (i.e. is the current condition work related?). Please describe.
- Has the treatment to date been reasonable and necessary relative to the work injury in question? If not, please note what has not been reasonable and explain why.
- Is any additional treatment and/or diagnostic testing medically necessary relative to the work injury in question? If additional care is needed, please specify the type, frequency and duration of that care.
- Has the employee reached maximum medical improvement (MMI) relative to the work injury in question? (MMI is defined as “the date after which no further significant recovery from or significant lasting improvement to a personal injury can reasonably be anticipated.” For injuries after October 1, 1995, this definition is expanded to include “irrespective and regardless of subjective complaints of pain.”)
- If MMI has been reached relative to the work injury in question, please offer a permanent partial disability rating, citing the appropriate section of the Minnesota Rules workers’ compensation disability schedule. Do not provide a rating if MMI has not been reached.
- Is the employee capable of working relative to the work injury in question? If only with restrictions, please specify those restrictions, indicating whether these restrictions are temporary or permanent. If temporary, please outline the duration.
- Additional Questions (Please be very specific in box below.)
MN WC Accepted Claim IME
Please let us know which questions you would like the doctor to address as part of this service:
- The diagnosis and cause of the current condition (i.e. is the current condition work related?). Please describe.
- Has the treatment to date been reasonable and necessary relative to the work injury in question? If not, please note what has not been reasonable and explain why.
- Is any additional treatment and/or diagnostic testing medically necessary relative to the work injury in question? If additional care is needed, please specify the type, frequency and duration of that care.
- Has the employee reached maximum medical improvement (MMI) relative to the work injury in question? (MMI is defined as “the date after which no further significant recovery from or significant lasting improvement to a personal injury can reasonably be anticipated.” For injuries after October 1, 1995, this definition is expanded to include “irrespective and regardless of subjective complaints of pain.”)
- If MMI has been reached relative to the work injury in question, please offer a permanent partial disability rating, citing the appropriate section of the Minnesota Rules workers’ compensation disability schedule. Do not provide a rating if MMI has not been reached.
- Is the employee capable of working relative to the work injury in question? If only with restrictions, please specify those restrictions, indicating whether these restrictions are temporary or permanent. If temporary, please outline the duration.
- Additional Questions (Please be very specific in box below.)
MN WC Accepted Claim IMRR
Please let us know which questions you would like the doctor to address as part of this service:
- The diagnosis and cause of the current condition (i.e. is the current condition work related?). Please describe.
- Has the treatment to date been reasonable and necessary relative to the alleged work injury in question? If not, please note what has not been reasonable and explain why.
- Is any additional treatment and/or diagnostic testing medically necessary relative to the alleged work injury in question? If additional care is needed, please specify the type, frequency and duration of that care.
- Has the employee reached maximum medical improvement (MMI) relative to the alleged work injury in question? (MMI is defined as “the date after which no further significant recovery from or significant lasting improvement to a personal injury can reasonably be anticipated.” For injuries after October 1, 1995, this definition is expanded to include “irrespective and regardless of subjective complaints of pain.”)
- If MMI has been reached relative to the alleged work injury in question, please offer a permanent partial disability rating, citing the appropriate section of the Minnesota Rules workers’ compensation disability schedule. Do not provide a rating if MMI has not been reached.
- Is the employee capable of working relative to the alleged work injury in question? If only with restrictions, please specify those restrictions, indicating whether these restrictions are temporary or permanent. If temporary, please outline the duration.
- Additional Questions (Please be very specific in box below.)
MN WC Not An Accepted Claim IME
Please let us know which questions you would like the doctor to address as part of this service:
- The diagnosis and cause of the current condition (i.e. is the current condition work related?). Please describe.
- Has the treatment to date been reasonable and necessary relative to the alleged work injury in question? If not, please note what has not been reasonable and explain why.
- Is any additional treatment and/or diagnostic testing medically necessary relative to the alleged work injury in question? If additional care is needed, please specify the type, frequency and duration of that care.
- Has the employee reached maximum medical improvement (MMI) relative to the alleged work injury in question? (MMI is defined as “the date after which no further significant recovery from or significant lasting improvement to a personal injury can reasonably be anticipated.” For injuries after October 1, 1995, this definition is expanded to include “irrespective and regardless of subjective complaints of pain.”)
- If MMI has been reached relative to the alleged work injury in question, please offer a permanent partial disability rating, citing the appropriate section of the Minnesota Rules workers’ compensation disability schedule. Do not provide a rating if MMI has not been reached.
- Is the employee capable of working relative to the alleged work injury in question? If only with restrictions, please specify those restrictions, indicating whether these restrictions are temporary or permanent. If temporary, please outline the duration.
- Additional Questions (Please be very specific in box below.)
MN WC Not An Accepted Claim IMRR
MN WC Additional Questions*
MN WC Additional Questions
Please let us know which questions you would like the doctor to address as part of this service:
- Please provide a diagnosis of the applicant’s condition.
- To a reasonable degree of medical probability is the diagnosis(es) causally related to the injury? In this regard, please address the following, providing your rationale for your opinion. Was the work incident in question the direct cause of the condition? Did the work incident precipitate, aggravate and accelerate a pre-existing condition beyond its normal progression? Was the condition a mere manifestation or appearance of symptoms of a pre-existing progressively deteriorating or degenerative condition?
- If the applicant is claiming an occupational disease (a condition caused by an appreciable period of work place exposure), please opine as to whether the work was a material contributory causative factor in the onset or progression of the condition beyond normal.
- With respect to the work injury, has the applicant reached an end of healing? If you believe the applicant has reached an end of healing, on what date did that occur? If the applicant has not reached an end of healing, when is that likely to occur?
- Please indicate to a reasonable degree of medical probability whether additional diagnostic testing and/or medical treatment is necessary to cure and relieve the effects of the work-related injury. Please be specific as to the treatment necessary, including type, frequency and duration.
- Is the applicant capable of working relative to the work injury in question? If restrictions are required, please indicate what restrictions are necessary and how long they should remain in place.
- Has the applicant sustained permanent partial disability as a result of the work-related medical condition? If so, please provide a numerical rating consistent with the Wisconsin Workers' Compensation guidelines. If you do not believe there was any permanent partial disability, please so indicate.
- Additional Questions (Please be very specific in box below.)
WI WC Accepted Claim IME
Please let us know which questions you would like the doctor to address as part of this service:
- Please provide a diagnosis of the applicant’s condition.
- To a reasonable degree of medical probability is the diagnosis(es) causally related to the injury? In this regard, please address the following, providing your rationale for your opinion. Was the work incident in question the direct cause of the condition? Did the work incident precipitate, aggravate and accelerate a pre-existing condition beyond its normal progression? Was the condition a mere manifestation or appearance of symptoms of a pre-existing progressively deteriorating or degenerative condition?
- If the applicant is claiming an occupational disease (a condition caused by an appreciable period of work place exposure), please opine as to whether the work was a material contributory causative factor in the onset or progression of the condition beyond normal.
- With respect to the work injury, has the applicant reached an end of healing? If you believe the applicant has reached an end of healing, on what date did that occur? If the applicant has not reached an end of healing, when is that likely to occur?
- Please indicate to a reasonable degree of medical probability whether additional diagnostic testing and/or medical treatment is necessary to cure and relieve the effects of the work-related injury. Please be specific as to the treatment necessary, including type, frequency and duration.
- Is the applicant capable of working relative to the work injury in question? If restrictions are required, please indicate what restrictions are necessary and how long they should remain in place.
- Has the applicant sustained permanent partial disability as a result of the work-related medical condition? If so, please provide a numerical rating consistent with the Wisconsin Workers' Compensation guidelines. If you do not believe there was any permanent partial disability, please so indicate.
- Additional Questions (Please be very specific in box below.)
WI WC Accepted Claim IMRR
Please let us know which questions you would like the doctor to address as part of this service:
- Please provide a diagnosis of the applicant’s condition.
- To a reasonable degree of medical probability is the diagnosis(es) causally related to the alleged injury? In this regard, please address the following, providing your rationale for your opinion. Was the work incident in question the direct cause of the condition? Did the work incident precipitate, aggravate and accelerate a pre-existing condition beyond its normal progression? Was the condition a mere manifestation or appearance of symptoms of a pre-existing progressively deteriorating or degenerative condition?
- If the applicant is claiming an occupational disease (a condition caused by an appreciable period of work place exposure), please opine as to whether the work was a material contributory causative factor in the onset or progression of the condition beyond normal.
- With respect to the alleged work injury, has the applicant reached an end of healing? If you believe the applicant has reached an end of healing, on what date did that occur? If the applicant has not reached an end of healing, when is that likely to occur?
- Please indicate to a reasonable degree of medical probability whether additional diagnostic testing and/or medical treatment is necessary to cure and relieve the effects of the alleged work-related injury. Please be specific as to the treatment necessary, including type, frequency and duration.
- Is the applicant capable of working relative to the alleged work injury in question? If restrictions are required, please indicate what restrictions are necessary and how long they should remain in place.
- Has the employee sustained permanent disability as a result of the alleged work-related medical condition? If so, please provide a numerical rating consistent with the Wisconsin Workers' Compensation guidelines. If you do not believe there was any permanent partial disability, please so indicate.
- Additional Questions (Please be very specific in box below.)
WI WC Not An Accepted Claim IME
Please let us know which questions you would like the doctor to address as part of this service:
- Please provide a diagnosis of the applicant’s condition.
- To a reasonable degree of medical probability is the diagnosis(es) causally related to the alleged injury? In this regard, please address the following, providing your rationale for your opinion. Was the work incident in question the direct cause of the condition? Did the work incident precipitate, aggravate and accelerate a pre-existing condition beyond its normal progression? Was the condition a mere manifestation or appearance of symptoms of a pre-existing progressively deteriorating or degenerative condition?
- If the applicant is claiming an occupational disease (a condition caused by an appreciable period of work place exposure), please opine as to whether the work was a material contributory causative factor in the onset or progression of the condition beyond normal.
- With respect to the alleged work injury, has the applicant reached an end of healing? If you believe the applicant has reached an end of healing, on what date did that occur? If the applicant has not reached an end of healing, when is that likely to occur?
- Please indicate to a reasonable degree of medical probability whether additional diagnostic testing and/or medical treatment is necessary to cure and relieve the effects of the alleged work-related injury. Please be specific as to the treatment necessary, including type, frequency and duration.
- Is the applicant capable of working relative to the alleged work injury in question? If restrictions are required, please indicate what restrictions are necessary and how long they should remain in place.
- Has the applicant sustained permanent partial disability as a result of the alleged work-related medical condition? If so, please provide a numerical rating consistent with the Wisconsin Workers' Compensation guidelines. If you do not believe there was any permanent partial disability, please so indicate.
- Additional Questions (Please be very specific in box below.)
WI WC Not An Accepted Claim IMRR
WI WC Additional Questions*
WI WC Additional Questions
Please let us know which questions you would like the doctor to address as part of this service:
- Regardless of causation, please specify the diagnosis.
- Do the objective findings support the subjective complaints? Please elaborate.
- Has the employee reached maximum medical improvement (MMI) as it relates to the work injury in question? If not, when do you expect MMI to be reached? (MMI is defined as “The point at which an employee has finished healing from an injury and has become medically stationary.”) Please explain.
- If maximum medical improvement has not been reached as it relates to the work injury in question, is any treatment and/or diagnostic testing necessary for the examinee to reach that point? If additional care is necessary, please specify the type, frequency, and duration of that care.
- Is the employee capable of working as it relates to the work injury in question? If only with restrictions, please specify those restrictions, indicating the anticipated duration.
- Additional Questions (Please be very specific in box below.)
IL WC Accepted Claim IME
Please let us know which questions you would like the doctor to address as part of this service:
- Please specify the diagnosis and cause of the current condition (i.e. is the current condition work related?). Please explain.
- Do the objective findings support the subjective complaints? Please elaborate.
- Has the employee reached maximum medical improvement (MMI) as it relates to the alleged work injury in question? If not, when do you expect MMI to be reached? (MMI is defined as “The point at which an employee has finished healing from an injury and has become medically stationary.”) Please explain.
- If maximum medical improvement has not been reached as it relates to the alleged work injury in question, is any treatment and/or diagnostic testing necessary for the examinee to reach that point? If additional care is necessary, please specify the type, frequency, and duration of that care.
- Is the employee capable of working as it relates to the alleged work injury in question? If only with restrictions, please specify those restrictions, indicating the anticipated duration.
- Additional Questions (Please be very specific in box below.)
IL WC Not an Accepted Claim IME
*
Please let us know which questions you would like the doctor to address as part of this service:
- Regardless of causation, please specify the diagnosis.
- Do the objective findings support the subjective complaints? Please elaborate.
- Has the employee reached maximum medical improvement (MMI) as it relates to the work injury in question? If not, when do you expect MMI to be reached? (MMI is defined as “The point at which an employee has finished healing from an injury and has become medically stationary.”) Please explain.
- If maximum medical improvement has not been reached as it relates to the work injury in question, is any treatment and/or diagnostic testing necessary for the examinee to reach that point? If additional care is necessary, please specify the type, frequency, and duration of that care.
- If MMI has been reached, please offer an impairment rating according to the AMA Guides to the Evaluation of Permanent Impairment, Sixth edition. Please follow the requirements for clinical evaluation, analysis of findings, and discussion of how the impairment rating was calculated, as listed on page 28 of the Guides. Do not provide a rating if MMI has not been reached.
- Is the employee capable of working as it relates to the work injury in question? If only with restrictions, please specify those restrictions, indicating the anticipated duration.
- Additional Questions (Please be very specific in box below.)
IL WC Accepted Claim IMER or IMRR
*
Please let us know which questions you would like the doctor to address as part of this service:
- Please specify the diagnosis and cause of the current condition (i.e. is the current condition work related?). Please explain.
- Do the objective findings support the subjective complaints? Please elaborate.
- Has the employee reached maximum medical improvement (MMI) as it relates to the alleged work injury in question? If not, when do you expect MMI to be reached? (MMI is defined as “The point at which an employee has finished healing from an injury and has become medically stationary.”) Please explain.
- If maximum medical improvement has not been reached as it relates to the alleged work injury in question, is any treatment and/or diagnostic testing necessary for the examinee to reach that point? If additional care is necessary, please specify the type, frequency, and duration of that care.
- If MMI has been reached, please offer an impairment rating according to the AMA Guides to the Evaluation of Permanent Impairment, Sixth edition. Please follow the requirements for clinical evaluation, analysis of findings, and discussion of how the impairment rating was calculated, as listed on page 28 of the Guides. Do not provide a rating if MMI has not been reached.
- Is the employee capable of working as it relates to the alleged work injury in question? If only with restrictions, please specify those restrictions, indicating the anticipated duration.
- Additional Questions (Please be very specific in box below.)
IL WC Not an Accepted Claim IMER or IMRR
*
Please let us know which questions you would like the doctor to address as part of this service:
- Please offer an impairment rating according to the AMA Guides to the Evaluation of Permanent Impairment, 6th edition. Please follow the requirements for clinical evaluation, analysis of findings, and discussion of how the impairment rating was calculated, as listed on page 28 of the Guides.
IL WC IRO
Would you like to inform others of this service, like a Nurse Case Manager and/or defense attorney?*
- Yes
- No
If you completed this form, you will automatically be included on updates for this service and you can check "No". Thank You.
Full Name of person you would like to keep informed:*
Role in this claim/service:*
- Nurse Case Manager
- Defense Attorney
Phone of person you would like to keep informed:*
Fax of person you would like to keep informed:
Email of person you would like to keep informed:*
Cover letter and Medical Records
If you have the medical records and/or cover letter ready for this service, please feel free to upload them at this time. If you need to upload them at a later time, please feel free to come back to our website to do so. You can also mail or overnight records to our office address: Woodlake Medical, 10400 Yellow Circle Drive, Suite 502, Minnetonka, MN 55343. If the medical records and/or cover letter aren't available at this time, our records team will send a reminder closer to the date of the service.
We appreciate and value your business. If there is anything we can do to make your ordering experience better, please let us know. We truly want this to be a useful tool, so we do appreciate your feedback. Feel free to discuss your ideas or concerns with your client service representative or email us at info@woodlakemedical.com. Have a great day!

	Phone: 952-253-6600 PhoneToll Free: 1-800-804-4008 Medical Records Direct: 952-253-6603
	Fax: 952-253-3900 Medical Records Fax: 1-888-645-1230

Service Order Request

Cover letter and Medical Records