Referrals

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 refer@pdmrtw.com
  • 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  
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
Claimant Name
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

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

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