< >Our File:<<File No>>Claim Number:<<Claim #>>

Insurance / Legal

Delivered by courier

<

<

<<CITY/PROV>>

< >

Dear <

RE: < > < >

DOB:< >

DOL:< >

Date/Time: <<DATE >>@ < >

Report Due: <<report due date>>

Thank you for agreeing to see this person for an <<Independent Medical Examination.>>

Please note there is a tight deadline of << deadline DATE>> for this report.

Please note there will be a videographer / interpreter present for this appointment.

The adjuster states that:

INSERT TAST

We enclose all documentation that has been made available to us. Please see the attached letter from our client, < > of < >, dated DATE with background issues and questions to be addressed in your report. Please respond in a question and answer format.

Please obtain a detailed history, review the enclosed documentation, perform an appropriate examination, and provide your opinion on the following points:

What is the diagnosis?

Is it solely responsible for the disability in question?

What role (if any) do pre-existing or unrelated conditions play in the present symptoms?

What are the objective abnormal findings on examination that support the present symptoms?

Please list inconsistencies or non-physiologic findings on history or examination.

Does the claimant have a defined clinical impairment?

Relative to any impairment, is this individual partially or totally disabled?

If so,

Please outline the claimant's specific physical limitations, if any, and how these may affect the performance of essential functions of the claimant’s occupation.

Please provide an estimated date for a return to work on either a graduated part-time or full-time basis.

What is the claimant's ability to resume all other activities and to do normal housework?

Are any further investigations required?

Does the claimant require treatment? If so,

What specific evidence-based non-pharmacologic treatment would you recommend as medically essential for treatment or rehabilitation of the disability? Please specify the frequency and duration required.

Please determine if any medication is now warranted for the disability. What dosage, frequency, and duration would you recommend?

In your opinion, has the claimant reached maximum medical improvement (MMI)? If not, please provide an estimate of time to full recovery to the status prior to the date of loss.

Please identify any barriers affecting recovery.

Please provide a short summary with your prognosis and conclusions.

When preparing your report, could you please address it to: < > of < >and quote the above referenced claim number.

PLEASE ENSURE THAT YOUR INVOICE AND REPORT ARE SENT ONLY TO WESTERN MEDICAL ASSESSMENTS.

Thank you for providing your services in this matter.

Yours sincerely,

Western Medical Assessments Corporation

Roger Hodkinson M.A., M.B. (Cantab), FRCPC

Medical Director

RGH/sz

Encls.