Complete all required fields (marked with an *):

Please include any previous or maiden names in parentheses behind the current last name.
Please note that foot and ankle claims will be referred elsewhere.
Include history of injury/disease, mechanism of injury, or other details as necessary.
Please review the medical notes and address the following questions on a medically more probable than not basis with a reasonable degree of medical certainty.
Check all that apply, as appropriate:
Medication related questions
Check all that apply, as appropriate:
OD related questions
Check all that apply, as appropriate:
Aggravation of previously accepted claim
Check all that apply, as appropriate:
Include any clarifying information or details you would like addressed by our physician that are not included above.
By submitting this form I (as the person listed above) authorize REOH to use these questions as the cover letter to be addressed in the IME for this claimant. *

If you don’t get a confirmation message, be sure you've answered all the required questions (marked with an *).  If you are still having trouble please contact Leah, lcm@reoh.com, for further assistance.