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Referral Information
Attorney/Referral Name*
Attorney/Referral Contact
Attorney/Referral Email Address*
Attorney/Referral Phone Number*
Attorney/Referral Address*
Street Address Address Line 2 City State ZIP Code

Patient Information
Patient Name
Patient Email Address
Patient Phone Number
Patient Address
Street Address Address Line 2 City State ZIP Code
Patient Date of Birth
MM slash DD slash YYYY
Patient's SS #

Type of Testing Requested:
- Impairment Rating
- X-Ray Digitizing

Injury Information
Date of Injury
MM slash DD slash YYYY
Brief Description of Incident
- Were X-rays Taken?
  - Yes
  - No
- What Areas Were X-Rays Taken Of?
  - Cervical
  - Cervical with APOM
  - Thoracic
  - Lumbar
- What Was the Source Image Distance (SID) for Cervical?
  - 40
  - 72
  - 72 SID for AP and 40 for the rest
  - Other
- Enter the Source Image Distance (SID) for Cervical
- What Was the Source Image Distance (SID) for Thoracic?
  - 40
  - 72
  - 72 SID for AP and 40 for the rest
  - Other
- Enter the Source Image Distance (SID) for Thoracic
- What Was the Source Image Distance (SID) for Lumbar?
  - 40
  - 72
  - 72 SID for AP and 40 for the rest
  - Other
- Enter the Source Image Distance (SID) for Lumbar
- What Was the Source Image Distance (SID) for Cervical with APOM?
  - 40
  - 72
  - 72 SID for AP and 40 for the rest
  - Other
- Enter the Source Image Distance (SID) for Cervical with APOM
- Were MRIs Taken?
  - Yes
  - No
- What Areas Were MRIs Taken Of?
- Were Injections Given?
  - Yes
  - No
- What Injections Were Given?
- Was Surgery Performed?
  - Yes
  - No
- What Surgery Was Performed?
- Was Surgery Recommended?
  - Yes
  - No
- What Surgery Was Recommended?
Impairment Rating
Areas to Perform Impairment Rating
- Cervical
- Thoracic
- Lumbar
- Shoulder
- Elbow
- Wrist
- Hip
- Knee
- Ankle
- Other
X-Ray Digitizing
Check Spinal Regions You Would Like Tested
- Cervical
- Cervical with AP Open Mouth Views
- Lumbar
Note: Digitizing x-rays requires that all films are are 100% or 1:1 ratio. Please do not reduce the size of the films. Pictures of films will not produce accurate results. The only views required for cervical and lumbar studies are lateral neutral, flexion and extension. For AP open mouth, we need the APOM and APOM right and left lateral views.

Insurance Information
Insurance Company Name
Policy Number
Claim Number
Claim Adjuster's Name
Type of Coverage
- PIP
- Med-Pay
- Lein/Letter of Protection
- Direct Payment
Insured's Name
Insured’s Date of Birth
MM slash DD slash YYYY
Insured's Sex
- Male
- Female
Insured’s Address
Street Address Address Line 2 City State ZIP Code
Patient’s Relationship to Insured
Status
- Single
- Married
- Divorced
- Separated
- Injuries Due To
  - Auto
  - Work
  - Other
- What Were Injuries Caused By?
State Where Injury Occurred

Where Will The Examination Be Performed?
- At ImpairMasters facility in Phoenix, AZ
- Location outside of Phoenix, AZ
Location Address
Street Address Address Line 2 City State
Location Phone Number
Please Attach Medical Records, X-Rays and/or Letter of Protection/Lien
Drop files here or

Max. file size: 100 MB.

The Premier Documentation and
Permanent Impairment Rating Solution

(480) 717-7885
[email protected]
20860 N Tatum Blvd, Suite 300
Phoenix, AZ 85050

Arizona’s Premier Documentation and Permanent Impairment Rating Solution

Contact Us

(602) 507-2866
[email protected]
20860 N Tatum Blvd, Suite 300, Phoenix, AZ 85050