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.

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Service Requested



Referral Source Information



Examinee Information



Insurance Carrier Information



Attorney Information



Issues to Be Addressed


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.



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