The first step in an independent medical review is to state the question that needs an answer. “Review the file” gives much less direction than a question tied to a condition, a period of treatment, or a specific clinical finding.
Start with the disputed issue
Identify where the medical opinions differ. Is the question about diagnosis, causation, whether additional treatment is medically indicated, the relationship of a pre-existing condition to the current findings, or work capacity? Separate distinct questions so the report can address each one directly. The referral should describe the issue without telling the physician what answer to reach.
Build a chronology
A concise timeline can orient the review: the reported event, earlier symptoms or diagnoses, testing, treatment, changes in condition, and the dates of the differing opinions. A timeline is an organizing aid; the underlying records still matter. If important dates are uncertain or records conflict, note that rather than silently resolving the conflict.
Provide records relevant to both sides of the question
Medical records can include office notes, diagnostic studies, imaging reports, hospital records, treatment plans, and prior history relevant to the issue. The goal is a complete and balanced set of material for the defined question, including records that may support different interpretations. Under Florida’s EMA statute, an appointed advisor is to have access to the employee’s medical records. The applicable process, scope, and transfer method should be confirmed for the particular referral.
Ask for an explanation, not just a conclusion
A useful opinion shows which facts carry weight, how competing evidence was considered, and where limits remain. It may need to distinguish a temporal association from a medically supported causal conclusion. If the available record cannot answer a question reliably, that limitation should be made explicit.
Protect the records
Send an initial inquiry with the case number and questions, but do not attach medical records to ordinary email. Arrange an appropriate secure transfer process with the receiving practice and follow any applicable case-specific instructions.