Independent Medical Examination Notice
Independent Medical Examination Notice
Before you use this: This is a letter from counsel for the person asked to undergo an examination. Confirm whether an examination is required by a court order, party agreement, insurance contract, or another applicable route. State only conditions supported by that source or proposed for agreement; do not assume a unilateral right to record, observe, limit, or refuse the examination.
[SENDER LAW FIRM AND ADDRESS]
[PHONE AND SECURE EMAIL]
[__/__/____]
Delivery: [METHOD AUTHORIZED BY RULE OR ORDER]
[RECIPIENT COUNSEL OR REQUESTING PARTY]
[ADDRESS]
Re: Examination of [PERSON], [CASE/CLAIM NUMBER]
Dear [NAME]:
We received your examination request dated [__/__/____] for [PERSON] by [EXAMINER NAME AND SPECIALTY] on [__/__/____] at [TIME, TIME ZONE, LOCATION]. The identified basis is [COURT ORDER, AGREEMENT, POLICY PROVISION, OR RULE AND PINPOINT]. Our response is selected below.
☐ Confirm: We confirm attendance on the stated date and terms shown in [ORDER OR AGREEMENT], subject to the practical coordination described below.
☐ Request change: We request [PRECISE CHANGE TO TIME, PLACE, EXAMINER, MANNER, OR SCOPE] because [FACTS AND SUPPORT]. Proposed replacement terms are [EXACT TERMS]. This is a request for agreement or court direction, not a declaration that the existing order has changed.
☐ Object: We object to [SPECIFIC REQUESTED ACT OR TERM] under [CURRENT RULE OR ORDER AND PINPOINT] because [FACTS AND GROUNDS]. We request [WITHDRAWAL, NARROWING, CONFERENCE, OR COURT DIRECTION] by [DATE]. We will address any still-operative obligation under the court's order and applicable rule.
| Examination term | Existing request/order | Agreed or proposed clarification |
|---|---|---|
| Condition and body part or issue | [DESCRIPTION] | [DESCRIPTION] |
| Date, duration and location | [DETAILS] | [DETAILS] |
| Examiner and permitted testing | [DETAILS] | [DETAILS] |
| Records supplied for review | [DETAILS] | [DETAILS] |
| Observer or recording, if authorized | [AUTHORITY AND TERMS / NONE] | [PROPOSAL OR NONE] |
| Accessibility, language or transportation | [NEED AND SOURCE] | [ARRANGEMENT] |
For a federal civil action governed by Fed. R. Civ. P. 35(a)(2), an order must specify the time, place, manner, conditions, scope, and examiner. The actual order in this matter is [DATE AND DOCKET ENTRY], and the requested clarification concerns [EXACT TERM]. For another forum or noncourt examination, the governing provision is [PINPOINT].
We request any examiner report through [SEPARATE REQUEST/AGREEMENT/ORDER AND PINPOINT]. Before making a federal Rule 35(b) report request, counsel will review its reciprocal-report and privilege consequences under the current rule. This letter does not set a universal fourteen-day report deadline or demand raw data, drafts, or credentials without an identified basis.
Please respond by [__/__/____] at [TIME AND TIME ZONE] to [CONTACT]. We are available to confer on [DATES]. If the matter needs a court ruling, identify the applicable filing and hearing schedule: [RULE OR ORDER].
Sincerely,
Signature: ______________________________
[COUNSEL NAME AND ROLE]
For [PERSON EXAMINED]
Enclosures: [ORDER, REQUEST, PROPOSED TERMS, OR "NONE"]
Delivery record: Sent [__/__/____] by [METHOD] to [DESTINATION]; proof [RECORD].
About this template
- Last updated
- September 27, 2026
- Jurisdiction
- All states
- Category
- Personal Injury
Legal authority
- Fed. R. Civ. P. 35(a)(2) (federal action only)
Personal injury cases are brought by people who were hurt because of someone else's carelessness: car crashes, slip and falls, defective products, and more. Demand letters, settlement agreements, and court filings in these cases have to document the injuries, the medical treatment, the lost income, and the exact legal basis for holding the other side responsible. Well-prepared paperwork is what drives higher settlements and forces insurers to take the claim seriously.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
The statutes this template relies on are listed under Legal authority.
Fed. R. Civ. P. 35(a)(2) (checked September 27, 2026): "must specify the time, place, manner, conditions, and scope of the examination, as well as the person or persons who will perform it."
Draft your Independent Medical Examination Notice in the editor
Answer a few questions, let the AI editor draft each section from your answers, review it, and download Word and PDF. $99 one time, or $249 per month for every document and every Ezel app.