Four Ways to Refer a File to PDM for Case Management

  • Internet. Fill out the form below and click the SUBMIT button at the bottom. After you submit the referral, you will be asked to e-mail, fax, or mail the FROI and medical records.
  • Email. E-mail referrals to
  • Fax. Click here to open our fax form.
  • Phone. Call us at 317-571-0702 to give us the referral over the phone.

Your Information
Service Request
Referred by   Service
Phone Other  

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

Comments, concerns, and/or special instructions
Attach related files...

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