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SCHEDULE A WORKERS’ COMP APPOINTMENT

Quickly and easily request a workers’ comp appointment with our world-class team. You may either call our scheduling center or fill out the form below and one of our scheduling team members will contact you to complete your worker’s comp registration.

Contact us by Phone:

Contact us Electronically: (Preferred)

Type of Appointment*
- New
- One Time Change
- Consult
- IME
- CME
- Out of State
Patient Information
Patient Name*
First Last
Date of Birth*
Address*
Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone Number*
Mobile Phone Number
Employer Name*
Workers' Compensation Insurance Carrier Information
W/C Company*
Phone Number*
Fax Number*
Address*
Address Line 2 City State / Province / Region ZIP / Postal Code Country
W/C Ins. Co. Billing Address (if different than above)
Address Line 2 City State / Province / Region ZIP / Postal Code Country
Claim Number*
Is this a Florida Claim?*
- Yes
- No
Adjuster/NCM Info
Adjuster*
Adjuster Phone*
Adjuster Fax*
Adjuster Email*
Nurse Case Manager
Nurse Case Manager Phone
Nurse Case Manager Fax
Nurse Case Manager Email
First Report of Injury
Has more than one area of the body been injured?*
- Yes
- No
Date of Injury*
Area of body injured
Choose specific area of choice above
List any other areas injured
Any fractures or lacerations?*
- Yes
- No
Can the patient reschedule appointment?*
- Yes
- No
Did the patient go to the emergency room or have any previous treatment?*
- Yes
- No
Are DME items of less than $200 authorized?*
- Yes
- No
Does the patient require a certified translator?*
- Yes
- No
Appointment Information
Physician Requested
Please upload medical records, diagnostic reports, and first report of injury.
Drop files here or

Accepted file types: jpg, png, pdf, docx, txt, tiff, Max. file size: 50 MB.
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