Workers' Compensation Appointment

Workers’ Compensation Appointment Form

Case Manager/Adjuster Contact Information

Name

Phone Number

Email Address

Fax Number

Patient Information

Patient Name

Patient Date of Birth

Patient Phone Number

Patient Email Address

Appointment Information

Doctor Preference

Please select the area needing care:

Is there a time of day preference?

If requesting to be seen immediately, please call our workers’ compensation team at (219) 706-1000.