---
title: Occupational Medicine to Disability Evaluation Specialist Referral Form Template | Paperform
description: Professional referral form template for occupational physicians to request independent medical examinations, functional capacity evaluations, and return-to-work determinations for workers' compensation cases.
url: "https://paperform.co/templates/occupational-medicine-to-disability-evaluation-specialist-referral-form"
type: static
generatedAt: "2026-03-28T00:44:40.029Z"
---

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When managing workers' compensation cases, occupational medicine physicians often need a streamlined way to refer patients to disability evaluation specialists for independent medical examinations (IMEs) and functional capacity evaluations (FCEs). This **Occupational Medicine to Disability Evaluation Specialist Referral Form** provides a structured, professional solution for healthcare providers managing complex return-to-work determinations.

This template is designed specifically for occupational medicine practices, workers' compensation clinics, corporate health centers, and disability evaluation services. It captures all essential information—from workers' compensation claim details and injury history to specific evaluation requests and medical documentation requirements—ensuring nothing falls through the cracks during the referral process.

**Paperform** makes this referral workflow seamless. The form's conditional logic adapts based on the type of evaluation requested, showing relevant fields for IME requests, FCE needs, or return-to-work assessments. You can embed it directly into your practice management system or share it via a custom link with referring physicians.

Beyond data collection, you can use **Stepper** (stepper.io) to automate what happens after submission. Route referrals to the appropriate specialist based on injury type, send automated notifications to case managers and insurance adjusters, create follow-up tasks for your administrative team, and sync patient data with your EHR or case management platform—all without manual data entry.

For practices requiring secure documentation and authorization signatures, **Papersign** (papersign.com) enables you to automatically generate referral authorization forms and send them for eSignature to all relevant parties, maintaining a complete audit trail for compliance and legal purposes.

This template is ideal for occupational medicine physicians, case managers, workers' compensation administrators, disability evaluation specialists, and corporate health coordinators who need a reliable, compliant solution for managing complex referral workflows in occupational health settings.
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