IPM Request for Interactive Process Facilitator Date Submitted Claim Representative Employer Rep’s Phone | email Employer’s Address Claims company Contact Person Phone | email Employee with the Medical Condition Employee’s Name Employee’s Phone Employee’s Address Email Occupation Date of Birth Date of Injury, Illness or Disability Working now? Injured Body Part(s) Work-related Injury? Yes No Claim # Medical Information Doctor’s Name Report Date Dr.’s Address Dr.’s Phone No. The above doctor is the: PTP QME AME Report Date Functional Limitations for a Return to Work Attorneys Defense Attorney Applicant Attorney Address Address City/State/Zip City/State/Zip Phone Phone Comments/Special Instructions Interpreter Needed YES NO Date form completed Job Description attached YES NO Authorization to Release Medical Report attached YES NO
