P.O. Box 12345,City, State ,RE: EXAMINEE : Abc,CLAIM NUMBER : 12345-67890,DATE OF INJURY : April 20, 2003,DATE OF EXAMINATION : August 26, 2003,EXAMINING PHYSICIANS : Y Z, DC,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. 
P.O. Box 12345,City , State , RE : EXAMINEE : Abc , CLAIM NUMBER : 12345 - 67890,DATE OF INJURY : April 20 , 2003,DATE OF EXAMINATION : August 26 , 2003,EXAMINING PHYSICIANS : Y Z , DC , Prior to the beginning of the examination , it is explained to the examinee that this examination is intended for evaluative purposes only , and that it is not intended to constitute a general medical examination .