MEDICAL CLAIMS EVALUATION SERVICE, LLC
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MEDICAL CLAIMS EVALUATION SERVICE, LLC
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Medical Claims Evaluation Service, LLC PO Box 22272 Pittsburgh, PA 15222 1-412-551-8771 Date physical exam date Attorney Name Firm Name Address City, State Zip Re: claimant name (examinee) Date of Injury: date Dear attorney name: An evaluation of examinee’s name was completed today including history, physical evaluation, and review of available records. A list of records reviewed is attached to this letter and is a part of this report. HISTORY OF INJURY AND INITIAL TREATMENT Examinee stated he/she was involved in type of accident on date of injury from above. Description of injury. Initial complaints. How transported and where to. Review of ambulance record if available. Confirms y/n. Why not? What happened at hospital? Review of ER record if any. Confirms y/n explain. Symptoms, evaluation, x-rays, treatment, condition on discharge. First treatment after hospital. Doctor’s name, date, symptoms, physical findings, radiological findings, treatment. Next treatment or objective test ( chronologically) etc. CURRENT SYMPTOMS From head down. CURRENT TREATMENT Name of current treating physicians, date most recent treatment, nature of treatment, medications. WORK HISTORY AND EDUCATIONAL ACHIEVEMENT Education and vocational qualification. Pre-injury work history. CURRENT IMPAIRMENT How examinee is limited by symptoms and condition, list of pre-injury capabilities and how restricted post-injury including work and recreational, and ADLs. Disability dates due to injury and treatment. Current work status. PAST HISTORY Detailed history of any prior injury or treatment to any area involved in current injury from patient or records. History of other major injuries not in same areas. Pertinent medical history and medication list. SUMMARY OF RADIOLOGICAL FINDINGS AND TEST RESULTS Listed by facility and date. State whether report, films or films and report reviewed. PHYSICAL EXAMINATION FINDINGS Head down. Correlate with symptoms? Y/n IMPRESSION Broader than just diagnosis. List in descending order of importance. DISCUSSION Nature of injuries and whether serious. How patient was affected, summary of major treatment, results of treatment, degree of recovery, how patient still affected, permanency, future treatment, costs of future treatment if requested.
DISABILITY AND IMPAIRMENT Disability status regarding work and recreational activities. Permanency. CAUSATION Within a reasonable degree of medical certainty injuries found on evaluation and treatment rendered were as a direct result of the event causing injuries. Contributing pre-existing factors if any and their relative importance. Aggravation, etc. ATTESTATION All conclusions and opinions stated in this report are stated within a reasonable degree of medical certainty and are based on the correlated information available from the examinee and records presented. They are based on the examiner’s experience as a type of doctor. This evaluation was performed solely for the purpose of creating this report and no treatment was rendered or recommended to the examinee based on this evaluation. The examinee remains under the care of his/her treating physician. If any further clarification is required, please notify me at the above address. SIGNATURE |
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