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

Insurance / Legal

Delivered by courier

<

<

<<CITY/PROV>>

< >

Dear <

RE: < > < >

DOB:< >

DOL:< >

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

Report Due:

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

Please note there is a tight deadline of < > 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:

FOR:

Minor Injury

Physical Disability

Physical Therapy

TMJ Evaluations

Addiction Evaluations

Psychiatric Evaluations

Summary of the Case

Relevant History

Diagnosis

Causation (on a balance of probability)

Treatment Plan

Return to Work recommendations

Answers to Specific Questioning

FOR:

Functional Ability Evaluations

Relevant History

Examination findings

Was maximum effort made?

Summary of findings relative to Job Desciption

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.