DMC Service Request Form

Disability Management Consultants, LLC
1532 McDaniel Drive, West Chester, PA 19380
Phone: 866-444-0320 Fax: 610-328-4014

DMC Service Request Form

Requester Information
REQUESTER CONTACT INFORMATION*

First NameLast Name
Requester Company

Address

CityState

Zip Code
Requester Phone
Requester Mobile Phone
Requester Fax
Requester Email

Claimant Information
CLAIMANT INFORMATION

First NameLast Name
Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Claimant Phone
Claimant Email
Claimant Date of Birth

MonthDayYear
Diagnosis Being Seen For

Attorney Information
ATTORNEY CONTACT INFORMATION

First NameLast Name
Attorney Company

Street Address

CityState

Zip Code
Attorney Phone
Attorney Fax
Attorney Email

Treating Provider Information
TREATING PROVIDER CONTACT INFORMATION

First NameLast Name
Treating Provider Practice Name

Street Address

CityState

Zip Code
Provider Specialty
Provider Phone
Provider Fax
Provider Email

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