Independent Medical Examination Notice
LITIGATION MEDICAL-EXAMINATION NOTICE AND RESPONSE DEVELOPMENT PACKET
NOT A NOTICE, OBJECTION, OR FILING. DO NOT SEND, SERVE, OR CHANGE AN
APPOINTMENT BASED ON THIS PACKET.
1. Case and Request Control
| Item | Verified entry | Source |
|---|---|---|
| Court / tribunal and jurisdiction | [________________________________] | [________________________________] |
| Caption and case number | [________________________________] | [________________________________] |
| Examined person and counsel | [________________________________] | [________________________________] |
| Requesting party and counsel | [________________________________] | [________________________________] |
| Claims and condition placed at issue | [________________________________] | [________________________________] |
| Current scheduling, discovery, privacy, and protective orders | [________________________________] | [________________________________] |
| Request, notice, stipulation, or order received | [________________________________] | [________________________________] |
| Examiner, specialty, and credentials | [________________________________] | [________________________________] |
| Proposed date, time, place, and duration | [________________________________] | [________________________________] |
| Prior examinations and reports | [________________________________] | [________________________________] |
2. Current Authority and Order Register
| Question | Current official rule / order and operative text | Matter-specific conclusion |
|---|---|---|
| Authority and prerequisites for examination | [________________________________] | [________________________________] |
| Leave, stipulation, notice, motion, or order route | [________________________________] | [________________________________] |
| Timing, frequency, location, and good-cause requirements | [________________________________] | [________________________________] |
| Examiner qualifications and conflicts | [________________________________] | [________________________________] |
| Scope, conditions, tests, history, records, and invasive procedures | [________________________________] | [________________________________] |
| Recording, observation, companion, interpreter, and accessibility | [________________________________] | [________________________________] |
| Travel, expenses, cancellation, and rescheduling | [________________________________] | [________________________________] |
| Report, findings, raw data, records, and reciprocal discovery | [________________________________] | [________________________________] |
| Privacy, privilege, confidentiality, and protective treatment | [________________________________] | [________________________________] |
| Objection, protective order, enforcement, and consequence | [________________________________] | [________________________________] |
3. Examination Fact Sheet
| Detail | Confirmed information | Open issue |
|---|---|---|
| Purpose and disputed condition | [________________________________] | [________________________________] |
| Examiner identity, specialty, licensure, and conflicts | [________________________________] | [________________________________] |
| Facility and accessibility | [________________________________] | [________________________________] |
| Expected history, physical tasks, tests, imaging, samples, or questionnaires | [________________________________] | [________________________________] |
| Documents and information supplied to examiner | [________________________________] | [________________________________] |
| Medication, mobility, language, safety, or accommodation needs | [________________________________] | [________________________________] |
| Transportation, travel, wage loss, and expense facts | [________________________________] | [________________________________] |
| Recording, companion, counsel, or observer request | [________________________________] | [________________________________] |
| Report and data delivery plan | [________________________________] | [________________________________] |
4. Communication Development
| Proposed document | Recipient | Deadline / trigger | Approved content |
|---|---|---|---|
| Examination notice | [________________________________] | [________________________________] | [________________________________] |
| Confirmation or stipulation | [________________________________] | [________________________________] | [________________________________] |
| Clarification / condition request | [________________________________] | [________________________________] | [________________________________] |
| Objection or protective request | [________________________________] | [________________________________] | [________________________________] |
| Accommodation or safety request | [________________________________] | [________________________________] | [________________________________] |
| Rescheduling or cancellation communication | [________________________________] | [________________________________] | [________________________________] |
5. Final Counsel Gate
☐ Current rules, orders, request papers, and local procedure were reviewed.
☐ The examiner, scope, conditions, logistics, privacy, and accessibility facts are accurate.
☐ No appointment was scheduled, missed, cancelled, or changed without approved instruction.
☐ The sending, filing, and service method and deadline are verified.
☐ Counsel approved a separate operative notice, stipulation, response, or motion.
Approved outgoing document / version: [________________________________]
Counsel approval / date: [________________________________]
About This Template
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.
Important Notice
This template is provided for informational purposes. It is not legal advice. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on 2026-09-03.
Last updated: 2026-09-03
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