STD/LTD Insurance Services

Claimant




Legal Representative (If Applicable)


Services Requested (select at least one service)


Independent Medical Evaluation (IME)

Functional Capacity Evaluation
Cognitive Demands Analysis
Physical Demands Analysis
Job Site Analysis
Ergonomic Assessment
Vocational Evaluation
Transferrable Skills Analysis
Labour Market Survey
Return to Work
Other - please specify in box below


Vocational Case Management
1-Point Assessment
2-Point Assessment
3-Point Assessment
Other - please specify in box below


Work Hardening/Conditioning
In-Home Exercise programs
In-clinic Exercise programs
Occupational Therapy Education/Treatment session
Progressive Goal Attainment Program (PGAP)
Other - please specify in box below

Referral Source