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MEDICAL BIOMECHANICS INC.

100 E. SAN MARCOS BOULEVARD, SUITE 400, SAN MARCOS, CA 92069

TELEPHONE: 760.751.0928  FAX: 760.751.0938  EMAIL: jputter@pol.net

www.medbiosciences.us ("www" required)

MEDICAL & BIOMECHANICAL SERVICE REQUEST FORM

Medical Biomechanics principal services include comprehensive record reviews, patient examinations, and testimony related to medical injuries in all of the specialties. Board Certified MDs at Universities or in private practice and engineers provide Medical and/or Biomechanical Reviews. MBI's Medical Director, an M.D. coordinates litigation support services and testimony nationwide to address specific aspects of injury causation, reasonable medical care, and disability. Case problems are reviewed by the Medical Director and selectively chosen qualified experts. Cases are reviewed in the areas of personal injury, medical malpractice, product liability, toxicology, pharmaceutical related injuries, workers' compensation, and criminal cases. Many case reviews involve automotive accidents and medical malpractice. In serious injury cases, life care plans are developed for the purpose of structuring an annuity. Medical Utilization Reviews and managed care assignments are also accepted upon request.

Please print out when completed

Date of Request: Individual Requesting Service:
Date Required: Title:
Claimant: Company/Firm:
Insured: Address:
Claim or File No.: Phone No.:
Date of Loss: Fax No.:

Email:

Please check all applicable service request items:

. Medical Review only . Independent Medical Evaluation
. Biomechanical Review only . Review of Special Diagnostic Tests
. Medical & Biomechanical Review . Bill Review or Other (Please Specify)

Please check and enclose the following information to expedite review:

Traffic Accident Report . Enclosed . Not Available
Statement of Occupants . Enclosed . Not Available
Repair Estimates (all vehicles) . Enclosed . Not Available
Vehicle Photographs (color/laser-all) . Enclosed . Not Available
Medical Records . Enclosed . Not Available
Radiographs . Enclosed . Not Available

Special Requests/Additional Comments
Please identify what type of medical specialist(s) you prefer for the review. Please identify any specific issues that you prefer to be addressed by the consultant(s).
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