Create Cover Letter | Medical Systems Inc Serving Wisconsin, Minnesota, Illinois and Michigan

Quickly draft a cover letter for each of your Medical Systems cases by providing the case summary and simply checking all interrogatories you wish to present to the doctor.

Case Parameters

All information in this section is required:

Claimant Name*:

Your File/Claim Number*:

Date of Injury*:

Type of Service (check one)*:

IME

Records Review

Addendum/Supplemental

Gender*:

Male

Female

Unknown

Case Summary

Please provide a summary of the injury claim below:

Specific Interrogatories:

To add a question to your cover letter, simply click the box to the left of each question. Easily edit any question by clicking inside the textbox under where the question appears.

Only questions you have checked will appear in your cover letter.

Diagnosis(es)/Causation

Please provide your diagnosis(es)

Please indicate any objective findings that support the diagnosis(es)

Please note any pre-existing conditions.

Is the above diagnosis(es) directly related to the incident in question?

If not directly related, is the diagnosis(es) related to the incident by precipitation, aggravation, and acceleration of a pre-existing condition beyond normal progression?

If the diagnosis(es) is related to the incident in question by precipitation, aggravation, and acceleration of a pre-existing condition, is the aggravation temporary or permanent? Please explain.

Was an appreciable period of workplace exposure the sole cause of the condition or at least a material contributory causative factor in the condition's onset or progression?

Is the diagnosis(es) a mere manifestation of a pre-existing deteriorating or degenerative condition which is unrelated to the incident/exposure in question?

Treatment

Has all treatment to date been reasonable, necessary and related to the incident/exposure in question? If not, please explain.

Is further treatment needed to cure and relieve the effects of the incident/exposure in question? Please explain and be specific as to further recommended treatment (including type, frequency and duration of treatment).

End of Healing/Maximum Medical Improvement

Has all treatment to date been reasonable, necessary and related to the incident/exposure in question? If not, please explain.

Return to Work/Restrictions

Is the claimant able to return to work? If so, as of what date?

If the claimant is able to return to work, can s/he return to work with or without restrictions?

If work restrictions are required, please provide a summary of the restrictions you recommend (include specific restrictions and duration of restrictions).

Please indicate your medical opinion as to whether these restrictions (either temporary or permanent) are related to the incident/exposure in question.

Please indicate your medical opinion as to whether any permanent restrictions are required. If so, please provide specific permanent restrictions.

Permanency

Disability:

Has permanent partial disability been sustained as a result of the incident/exposure in question?

If so, please indicate the specific percentage of permanency sustained based on the appropriate guidelines.

If you conclude the claimant suffered a direct injury or an injury by precipitation, aggravation, and acceleration of a preexisting condition AND you conclude that the injury resulted in permanent partial disability, please answer the following question: what portion of the disability is due to the workplace injury and what portion of the disability is due to other factors such as preexisting conditions, comorbidities, etc.?

Impairment

Has the incident in question caused permanent impairment? If so, please state the percentage of permanent impairment related to the incident in question using the appropriate guidelines and explain how you reached this rating.

Custom Question:

Use this section to ask additional question(s) not listed above:

Closing Information:

Please edit the below textbox to fit your case, or the below text will appear in your cover letter:

When you are ready to submit the completed cover letter, provide your email address below and click Review Draft. You then have the opportunity to review a draft of your cover letter. You can then submit the completed letter or make additional changes to the letter before submitting as final.

Your Email Address*

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