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	On-Site / Full Service Case Management Task Assignment Telephonic Case Management Telephonic Triage Assessment Chronological Nurse Case Study Length of Stay/Continued Stay Review Only Peer Review Physician Advisor File Review Pre-Certification of Treatment Other
Phone			Other
E-mail
Company
Claim Information			Primary Treating Physician
Insurance Coverage	Unspecified Worker's Compensation H & A Liability Disability		Physician Name
Claim's State Jurisdiction	Unspecified IN IL KS KY MI MO OH TN WI		Physician Phone
Date of Injury
Claim Number
Is the claimant aware of PDM's involvement? Unspecified Yes No Is the claimant working? Unspecified Yes No Is the claimant represented? Unspecified Yes No How are you sending medical records to PDM?  Unspecified Attached to Referral Mail Fax E-mail None			Plaintiff Attorney Attorney Name Attorney Phone
Claimant			Anti-Spam
Claimant Name			Type 7932 in Textbox <<
Date of Birth
Gender	Unspecified Male Female
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
Comments, concerns, and/or special instructions     (Do not type more than five lines.)