Medical Investigation Group, Inc.
Medical Investigation Group


Upcoming Events

PLRB Regional Adjusters Conferences
September 6-7, 2017
New Orleans, LA
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IASIU Annual Conference
September 10-13, 2017
New Orleans, LA
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CASE REFERRAL FORM

* Required Fields

Analyst Information

Claimant/Insured Information

Services Requested (choose at least one) *

Facility Inspection
Provider Interview/EUO
"Cold Call" to Provider
Medical Record/Chart Review
Medical Records/Film Retrieval
License Check
Initial Review
Case selection consult
Credential Check
Background Check
Recorded Statement
Surveillance
Corporate Check
Other
Retainer (TBD)
Database scan

Case Description/Circumstances of Claim Injury *


Characters Remaining:
 

Provider Names/Locations

Attorney Information (optional)