Special Exam Requests

Independent Medical Exam (IME)
Comprehensive Second Opinion (CSO)

Thank you for choosing OrthoArkansas for your special service request. Our orthopedic trained physicians have the expertise to evaluate for compensability, appropriate diagnoses and treatment. We look forward to providing the utmost care to the patient and providing clear and timely communication with the scheduling party.

Contact Workers’ Compensation Team

Phone: 501-500-1750
Email: workcomp@orthoarkansas.com

SPECIAL EXAM REQUIREMENTS

Medical Records:
Complete medical records along with a cover letter are required for each special exam.

Records are accepted two ways:
By Email: workcomp@orthoarkansas.com

By Mail: 800 Fair Park Blvd., Little Rock, AR 72204 ATTN: Workers Compensation Department

Imaging:
All prior imaging related to this compensable body part must be provided prior to — or at the time of appointment.

Procedure for Scheduling Exam

The Special Exam Request Form and complete medical records will be presented to the physician for review/consideration
If the physician agrees to the special exam, an invoice will be sent to the requesting party for pre-payment
Appointment will be scheduled

REQUEST A SPECIAL EXAM BY SUBMITTING THE FORM BELOW. This information will be sent directly to our Workers’ Compensation Team, and someone will respond promptly.

Special Exam Requested

Independent Medical Exam (IME) Independent Medical Exam with Option to Treat Second Opinion Second Opinion with Transfer of Care

Patient's Name

Patient Date of Birth

Patient Adress

Patient Phone Number

Patient Email

Employer

Employer Adress (Including City, State, ZIP code)

Scheduling Party Name

Scheduling Party Phone Number

Scheduling Party Email

Adjuster Name

Adjuster Phone Number

Adjuster Fax

Adjuster Email

Insurance Carrier

Insurance Carrier Billing Address

Claim Number

Date of Injury

If you have a provider preference, please list in the space below.

Body Part(s) to be evaluated

Please list all previous imaging (MRI, CT, EMG/NVC, etc) related to the body part being evaluated. Include year and type of image.

Please list all previous surgical and non-surgical procedures related to the body part being evaluated. Include year and type of procedure.

List any previous providers the patient has seen regarding the body part being evaluated.

Please provide specific questions that should be addressed by the physician, or a cover letter with questions must be provided with submitted medical records.

Special Exam Requests

Independent Medical Exam (IME)Comprehensive Second Opinion (CSO)

Contact Workers’ Compensation Team

SPECIAL EXAM REQUIREMENTS

Procedure for Scheduling Exam

Independent Medical Exam (IME)
Comprehensive Second Opinion (CSO)