Fill out the form below, print it, and fax it to either (317) 571-0721 or (888) 393-5033. Please fax FROI and medical records. Mail large meds to the address to the right. The case manager assigned to your file will contact you within 24 hours. Thank you!     Preferred Disability Management
11711 North Meridian Street, Suite 760
Carmel, IN 46032

Your Information
   
Service Request
Referred by   Service
Phone Other  
E-mail
Company

Claim Information

Primary Treating Physician
Insurance Coverage Physician Name
Claim's State Jurisdiction Physician Phone
Date of Injury
Claim Number
 
Is the claimant aware of PDM's involvement?
Is the claimant working?
Is the claimant represented?
How are you sending medical records to PDM? 
Plaintiff Attorney
Attorney Name
Attorney Phone

Claimant

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Claimant SSN
Date of Birth
Gender
Claimant Address
Claimant City, State ZIP
Claimant Phone
Claimant Mobile Phone
Claimant E-mail
Diagnoses
Employer / Insured
Employer Contact Name
Employer Contact Phone
Employer Email Address

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