< >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 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:

Did an injury occur as a result of the index motor vehicle accident?

If so, is it solely due to the motor vehicle accident 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 (Waddell's signs).

Does the claimant have a defined clinical impairment? If yes, please indicate if it is due directly to the motor vehicle accident, and independent of all other causes? (We ask that you not refer to percentage of total body impairment)

Relative to the MVA, is this individual partially or totally disabled?

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 pre-accident activities and to do normal housework?

Relative to the MVA, does the claimant require treatment? If so,

What specific evidence-based treatment modalities would you recommend as medically essential for treatment or rehabilitation due to injuries sustained in the MVA? Please specify the frequency and duration required.

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

Relative to the MVA, in your opinion, has the claimant reached maximum medical improvement (MMI)? If not, please provide an estimate of time to full recovery to the pre-accident status.

Please identify any barriers affecting recovery.

Relative to the MVA, 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.