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Scheduling Request

Please fill out our Scheduling Request Form

PLEASE NOTE: Keep records upload sizes 20MB and under. For larger files, please email them to us at Records@cdcime.com.

If you just want to upload additional records, please click here.

Thank you for connecting with us. We will respond to you shortly.

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Service Type

Referral Type*

Workers Comp

Auto

Legal

Type of Exam*

IME

Permanency Evaluation

Addendum

Record Review

Peer Review

FMLA

2nd Opinion

Additional Services*

Translation

Transportation

Case Manager

Case Management Cover Letter

No Additional Services Needed

Language Type Needed

Spanish

French

Mandarin

Hindi

Arabic

Other

Referral Source*

Adjuster

Defense Attorney

Plaintiff Attorney

Case Manager

Referral Source Information

First Name*

Last Name*

Phone Number*

Email*

Claimant Information

First Name*

Last Name*

Date of Birth*

Gender*

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Social Security Number*

Claimant Phone Number*

Claimant Employer*

Claim Number*

State of Jurisdiction*

Date of Injury*

Injury / Body Parts*

Specialty Needed*

Second Claim Information

Secondary Claim Information

Second Date of Injury

State of Jurisdiction

Injury/Body Parts

Treating Physician

Treating Physician Name*

Requested Physician

Is there a doctor you would like us to use?

Requested Physician Name

Phone Number

Specialty

Special Instructions / Comments

Medical Record Upload

Records UploadPDF, Word, Excel, JPEG, PNG, and MP4 allowed. To upload multiple files select while holding down the command key. Maximum upload size: 20MB. For files that are not supported, please email to Records@cdcime.com.

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doc,docx,mpg,mpeg,mp3,mp4,odt,odp,ods,pdf,ppt,pptx,txt,xls,xlsx,jpg,jpeg,png

Upload Additional Records

Please upload any additional records you may have here.

Claimant Name

Date of Injury

Service Type

Provider Scheduled With

Additional Records UploadPDF, Word, Excel, JPEG, PNG, and MP4 allowed. To upload multiple files select while holding down the command key. Maximum upload size: 20MB. For files that are not supported, please email to Records@cdcime.com.

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doc,docx,mpg,mpeg,mp3,mp4,odt,odp,ods,pdf,ppt,pptx,txt,xls,xlsx,jpg,jpeg,png

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