IPM Summary Form

Request for Interactive Process Facilitator: Workers Compensation-related

Date Rcvd by Claims Dr. D. Dupree

Claim Representative

Employer

Rep’s Phone | email

Employer’s Address

Claims company

Contact Person

Phone | email

Employee with the Medical Condition

Employee’s Name

Employee’s Phone

Employee’s Address

Occupation

Date of Birth

Date of Injury, Illness or Disability

Working now?

Injured Body Part(s)

Work-related Injury?

Claim #

Medical Information

Doctor’s Name

Report Date

Dr.’s Address

Dr.’s Phone No.

Is the above Doctor:

Report Date

Functional Limitationsfor a Return to Work

Attorneys

Defense Attorney

Applicant Attorney

Address

Address

City/State/Zip

City/State/Zip

Phone

Phone

Comments/Special Instructions

Interpreter Needed

Date form completed

Job Description attached

Authorization to Release Medical Report attached