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 888-222-PDM1 to give us the referral over the phone.
Your Information
Service Request
Referred by
Service
On-Site / Full Service Case Management
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
Mail
Fax
E-mail
None
Plaintiff Attorney
Attorney Name
Attorney Phone
Claimant
Claimant Name
Claimant SSN
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
Comments, concerns, and/or special instructions (Do not type more than five lines.)
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