I M X Request Form

Request Form

Please complete the on-line service request below and click the submit button to transmit the information to the appropriate party at IMX. Once submitted you will receive an automated response which will include all the referral information provided. Simply print the response and attach it to the file for the IMX representative to retrieve from the referral bin.

Referrer and Billing Information

Referral Party Information

Referring Company

Referring Source

Address

Phone

Fax

Bill To Information

Check here if same as Referral Party

Contact Name

Company Name

Address

Phone

Fax

Claimant and Physician Information

Claimant Details

Last Name

First Name

Address

Home Phone Number

Work Phone Number

Social Security Number
###-##-

Date of Birth

Gender

Employer

Occupation

Language

Claim Number

Date of Accident/ Injury

Injury Description / Nature of Injury

Background of Injury

Currently Working

Claim Accepted

Jurisdiction

Type of Claim

WCB #

Type of Service

Treating Physician(s) Add Treating Physician

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Other Needs

Transportation

Translation

Conference Call

Attorney Information

Defense Attorney Information

Attorney Name

Firm Name

Address

Phone Number

Fax

Contact for Input

Claimant Attorney Information

Attorney Name

Firm Name

Address

Phone Number

Fax

Appointment Information

Appointment Details

Specialty

If other, please specify

Provider

Location

Appointment Date to Take Place By

Time

Report Completed By

Reason For Report Rush Date

X-Rays Approved

Special Instructions / Price Restrictions

Notification of Appointment

Send Appointment Letter to Claimant

Copy to Claimant's Attorney

Copy to Defense Attorney

Copy to Referring Party

Copy to Billing Party

Do Not Send Notifications

File Uploads

Select Files

Drag file(s) here or click on Browse below

File Uploads

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Allowed File Types

.doc, .docx, .xls, .xlsx, .txt, .csv, .pdf, .jpg, .tif, .tiff, .zip, .mp3, .msg, .avi, .mov, .wmv, .mp4

Maximum File Size

100MB

Maximum File Count

10 Files

This electronic Request Form utilizes state of the art security and data encryption. By activating the browser's "LOCK" icon, the IMX Portal's Security Certificate employs 256-bit data encryption TSL (Transport Layer Security) and assures online visitors that confidential information cannot be viewed, intercepted or altered in any way.

Form Information Confirmation

Please check this box to confirm this form is complete and accurate.

Request Form

Referrer and Billing Information

Claimant and Physician Information

Issues and Items to Address

Attorney Information

Appointment Information

File Uploads

Form Information Confirmation