Below is a sample of the emails you can expect to receive when signed up to Eval Specialists.
Claimant Information | |
Claimant:* |
Home Phone: |
Address:* |
DOB:* |
City:* |
SS#: |
State:* |
Zip:* |
If Evaluation Specialists is sending the scheduling letter: | |
Claimant Attorney: |
Address: |
City: |
State: |
Zip: |
|
Claim Information | |
Employer: |
DOI: |
Job Title: |
WC: Auto: LIA: Other: |
Type of Injury:* |
Claim Number:* |
Examination Information | |
Reason for Examination: |
Date Exam Needed By: |
Speciality or Physician Requested: |
Location: |
Case Manager Attending Yes No |
Eval Specialists Sending Notification Letter to Patient? Yes No |
Address Report To | |
Your Name:* |
Phone:* |
Company:* |
Fax: |
Address: |
Email: |
City: |
State: |
Zip: |
|
Billing Information (if different from above) | |
Name:* |
Company:* |
Address: |
City: |
State: |
Zip: |
Phone:* |
Fax: |
Additional Information | |
Data Name | Data Type | Options |
---|---|---|
Printer Friendly Claimant Information Claimant: | Text Box | |
Title | Text Box | |
Text Box | ||
Phone (home) | Text Box | |
Home address | Text Box | |
City | Text Box | |
State | Text Box | |
Zipcode | Text Box | |
Date of birth | Text Box | |
checklist | WC: | |
checklist | Auto: | |
checklist | LIA: | |
checklist | Other: | |
option | Case Manager Attending | |
option | Yes | |
option | No Eval Specialists Sending Notification Letter to Patient? | |
option | Yes |