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IME Request Form — Ogiso Health

Request an Independent Medical Examination (IME)

To initiate an IME at Ogiso Health, submit your request by phone or email using the intake checklist below. All IME requests are reviewed by Dr. Olatunde Oso prior to scheduling to confirm scope, appropriateness, and timeline. Reports are typically delivered within 10–14 business days of the examination date.

Phone: 615-397-6243  |  Email: ogisohealth@gmail.com  |  Fax: (if applicable — confirm at intake)


IME Request Checklist

Please include all of the following when submitting your IME request. Incomplete submissions will delay scheduling.

1. Requesting Party Information

  • Name and title of the person making the request
  • Organization name (law firm, insurance carrier, employer, TPA, or self)
  • Mailing address
  • Phone number and email address
  • Billing contact (if different from requesting party)
  • Type of requesting party:
    • ☐ Attorney (Plaintiff)
    • ☐ Attorney (Defense)
    • ☐ Workers' Compensation Carrier
    • ☐ Long-Term Disability Carrier
    • ☐ Employer / HR
    • ☐ Third-Party Administrator (TPA)
    • ☐ Individual / Self-Pay
    • ☐ Other: ___________

2. Examinee Information

  • Full legal name
  • Date of birth
  • Gender
  • Contact phone number and address (for scheduling notification)
  • Preferred language (if interpreter needed)
  • Any relevant mobility or accommodation needs

3. Case / Claim Information

  • Claim number or case reference (if applicable)
  • Date of injury, incident, or onset of condition
  • Jurisdiction (if workers' compensation — Tennessee or other state)
  • Brief description of how the injury or condition occurred
  • Current work status: ☐ Working full duty   ☐ Working with restrictions   ☐ Off work
  • Current treating physicians and specialties (list all)
  • Has the examinee reached Maximum Medical Improvement (MMI)? ☐ Yes   ☐ No   ☐ Unknown

4. Conditions to Be Evaluated

  • List all diagnoses or body parts/conditions to be addressed in the IME
  • Specify primary and secondary conditions if applicable

5. Specific Questions to Be Addressed

Please list the specific medical-legal questions you need the IME report to answer. Common questions include:

  • Is the diagnosis causally related to the described mechanism of injury?
  • Has the examinee reached Maximum Medical Improvement?
  • What is the degree of permanent partial impairment (AMA Guides)?
  • Is the proposed treatment medically necessary and causally related?
  • Are there any pre-existing conditions that contributed to the current condition?
  • Is the examinee medically fit to return to their previous job duties?
  • What work restrictions, if any, are medically appropriate?
  • Are future medical treatments anticipated? If so, what?

You may add custom questions. The report will address each question listed at the time of intake.

6. Records Submission

  • All relevant medical records (treating physician notes, operative reports, imaging reports, therapy records)
  • Diagnostic imaging (MRI, X-ray, CT reports — reports and/or films)
  • Prior IME or FCE reports (if available)
  • Job description (for fitness-for-duty or return-to-work cases)
  • Deposition transcripts (if applicable)

Records submission deadline: All records must be received at least 5 business days before the scheduled examination date to allow adequate review time. Late record submissions may require rescheduling.

7. Report Requirements

  • Standard report format: ☐ Yes   ☐ Custom format required (attach template)
  • Delivery method: ☐ Email (PDF)   ☐ Secure portal   ☐ Fax   ☐ Mail
  • Copy to examinee's counsel: ☐ Yes   ☐ No
  • Is expert testimony or deposition anticipated? ☐ Yes   ☐ No   ☐ Possibly

Fees and Payment

The comprehensive IME package is billed at a flat fee of $2,500. This covers:

  • Pre-examination records review
  • In-person physical examination
  • Written medical opinion report addressing all submitted questions

Additional fees (quoted separately):

  • Deposition preparation and attendance
  • Trial testimony
  • Supplemental or addendum reports
  • Rush report requests (delivery in fewer than 7 business days)

Financial Disclosure

Payment is due from the requesting party prior to or at the time of examination. Ogiso Health does not bill health insurance for IME services — these are not treatment visits. Accepted payment methods: check (payable to Ogiso Health), ACH bank transfer, and major credit cards. Employer accounts and law firm accounts may request net-30 billing terms — contact us to discuss. Cancellations within 48 hours of the scheduled examination may be subject to a cancellation fee.


What Happens After You Submit

  1. Intake review (1–2 business days): Dr. Oso reviews the case summary and questions to confirm the evaluation is within scope and appropriate.
  2. Scheduling confirmation: You receive a scheduled examination date and records submission deadline.
  3. Records review: All submitted records are reviewed before the examination.
  4. Examination: The examinee presents at 2700 Gallatin Pike, Suite D, Nashville, TN 37216.
  5. Report delivery: Written report delivered within 10–14 business days of the examination.

Questions before submitting? Call 615-397-6243 to speak with our office directly. We are happy to discuss the scope of the evaluation before you commit.

Ogiso Health serves attorneys, insurance carriers, employers, and individuals throughout Tennessee. Dr. Olatunde Oso is Board-Certified in Preventive and Occupational Medicine.