IME Request

Locations

Arlington Heights
Alsip
Bolingbrook
Chicago
Countryside
Elmhurst
Glenview
Oak Lawn
Vernon Hills

IME Request Form

Please enter preferred appointment dates (mm-dd-yy) *

Locations and Physicians available at each:

Arlington Heights
Michael Vender, MD
Scott Sagerman, MD
Prasant Atluri, MD
Sam Biafora, MD
Michael V. Birman, M.D.

Alsip
Michael Vender, MD
Sam Biafora, MD

Bolingbrook
Scott Sagerman, MD

Chicago
Michael Vender, MD
Prasant Atluri, MD

Countryside
Scott Sagerman, MD

Elmhurst
Prasant Atluri, MD

Glenview
Michael Vender, MD

Oak Lawn
Prasant Atluri, MD

Vernon Hills
Scott Sagerman, MD
Sam Biafora, MD

Preferred physician (in order of preference if more than one selected above) *

Preferred locations (in order of preference if more than one selected above) *

Patient Information

Area to be Examined or condition to be evaluated: *

Patient Name *

First

Last

Gender *

Male Female

Date of Birth (mm-dd-yy) *

Patient Address *

Line 1

Line 2

City

State

Zip Code

Country

Patient's Primary Phone Number *

Home Work Cell

Patient's Secondary Phone Number *

Home Work Cell

IME Appointment Requester

IME Appointment Requester Name *

First

Last

IME Appointment Requester Email *

Insurer

Adjuster's Name *

First

Last

Organization *

Adjuster's Address *

Line 1

Line 2

City

State

Zip Code

Country

Work Phone Number *

Fax Number *

Email *

Additional Comments *

Physicians

Michael I. Vender, M.D.
         Scott D. Sagerman, M.D.
         Prasant Atluri, M.D.
          Sam Biafora, M.D.
  Michael V. Birman, M.D.

Phone:
Fax:

(847) 956-0099
(847) 956-0433

Specialists in the Shoulder, Elbow, Wrist & Hand

Hand Surgery Associates, S.C.