Independent Medical Exam Request

In order for us to properly process your request for services, there are key factors of information that must be provided. This will allow us to accurately process your request. Should you find difficulty in providing the necessary information, we ask that you contact us at (866) 880-0865 and one of our associates will assist you.

Fields marked with an * are required
 

 

Service Requested


 

 

Referral Source Information


 

 

Examinee Information


 

 

Insurance Carrier Information


 

 

Attorney Information


 

 

Issues to Be Addressed


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Phone: (440) 933-0700
Toll Free: (866) 880-0865

 

Disability Exam Consultants, LLC
P.O. Box 207
Avon Lake, Ohio 44012
For all other questions
and general information,
please reach out below.

 

 

Email Our Team