Online IME Request Form

Please complete the secure form below and an MHS representative will contact you as soon as possible to schedule an IME. The information you submit is private. If you have questions, please call 630-359-6888.

* Indicates required fields.

MHS IME Request Form Step 1

IME/Impairment Rating Appointment Request: Midwest Hand Surgery
IME Requested By: *
First Name Last Name
Phone Number * Fax Number Email *
Bill & Report Information
Send Bill To: *
First Name Last Name
Email * Company Name *
Company Address: *
Street Address 1 Street Address 2
City State / Province
Postal / Zip Code Country
Phone Number * Fax Number
Would you like to send an additional report to a 2nd Party:
Yes No