Interested in partnering with MCN? Fill out this form and we will contact you to discuss this opportunity.
First Name:
Last Name:
Email:
Office Phone:
Home/Cell Phone:
Specialty:
Sub-Specialty:
Area(s) of expertise:
Scheduling Contact:
Fax:
Street Address:
City:
State:
Postal Code:
Please indicate which type(s) of evaluations you are interested in, and whether or not you're currently experienced in performing them:
Independent Medical Exams:
Interested
Experienced
Peer Reviews:
Interested
Experienced
Disability Peer Reviews:
Interested
Experienced
Utilization/External Reviews:
Interested
Experienced
Do you have experience citing evidenced-based medicine in Peer Review Reports (i.e.
Official Disability Guidelines
)? List evidenced-based medicine sources you’re familiar with:
If you have experience providing impairment ratings, please list which methods you're familiar with (i.e.
AMA 6th Edition
):
Medical Records Preference:
Hard Copy
Email
Fax
Website
Report Method:
Dial-in Dictation
Email
Fax
Website
Please list any foreign languages you speak:
