<Insurance carrier>
<planner>
RE: <claimant>
Claim #: <#>
]
<free text box>
Ex Parte Communication Notice:
By requesting Complex Claim services it may be necessary for ExamWorks
Clinical Solutions to communicate with the claimants medical providers. We
assume you have authorization under the law or have obtained proper
written authorization from the claimant which allows ExamWorks Clinical
Solutions to communicate with the claimants medical providers. Please
forward a copy of signed authorizations, if applicable. If you do not have
authorization, please advise us immediately. If authorization is
necessary, ExamWorks Resolution Services are available to obtain the
executed authorization form from the claimant or through their attorney. Your
dedicated ExamWorks Account Executive can provide pricing information for
these services.
[Populate text box with:]
Please advise if you would like us to follow up on the recommendation for
<service product>. Contact your Account Executive, <AE name>, at <AE
phone> for further details and pricing information.
OR
The (service product) will be initiated. You will receive a report in thirty days
with a progress update.
If you have any questions or concerns, please contact me.
Thank you for the referral.
< File Owners name>
ExamWorks Clinical Solutions
Phone: <#>
Fax: (866) 883-1867
<File owners email address>
cc: <adjusters name and email address>
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