Scheduling

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Your Information
Your Name*
First Last
Email*
Phone Number*
Company*
Adjuster Information (if applicable)
Please fill out this section if you are not the adjuster on the claim
Name
First Last
Email
Phone Number
Company
Claimant Information
Claimant Name*
First Last
Claim Number*
Claimant Address*
Street Address Address Line 2 City State ZIP Code
Claimant Phone Number*
Date of Birth*
MM slash DD slash YYYY
Select One*
- Workers Comp
- Motor Vehicle Accident
- Other
DOI *
Employer at the time of injury *
DOL *
Report Deadline (if applicable)
Appointment Information
Body Part(s)*
Single/Panel*
- Single Exam
- Panel Exam
If this is a Single Exam, make one selection below. If it is a Panel Exam, please make two or more selections.
Specialty *
Specialty (Other)*
First Specialty *
First Specialty (Other)*
Second Specialty*
Second Specialty (Other)*
Third Specialty (If applicable)
Third Specialty (Other)
Preferred Exam Location
Preferred Physician (If applicable)
Claimant's Attorney Information
Attorney's Name or Firm Name
Address
Street Address Address Line 2 City State ZIP Code
Phone Number
Interpreter Services
Does the Claimant speak English?*
- Yes
- No
Language*
Travel Arrangements
Please select from the drop down menu which travel arrangements you would like for us to coordinate.
Diagnostic Request
Would you like Integrity to request diagnostics on your behalf?*
Notes
Upload File
If you would like for us to request diagnostics on your behalf and you have access to the 801, 827, or any other medical release, please upload that below so we can get a head start on the request. Make sure to list the facility name(s) above.
Max. file size: 1 GB.
Medical Record Delivery
Please let us know how you will be submitting the medical records*
Secure Upload Instructions:
You can submit the medical record(s) by using the menu to navigate to our Medical Record Upload page. Don't forget to submit this scheduling form first.
Medical Record Email Instructions:
Email your medical record to records@integritymed.us.com. Don't forget to submit this scheduling form first.
Pick Up Instructions:
In the additional comments section, please let us know the best time to swing by and pick up the medical record(s).
Mail Instructions:
Mail your medical record(s) to our corporate address:

INTEGRITY MEDICAL EVALUATIONS
5845 Shoreview Ln. N.
Keizer, OR 97303
Fax Instructions:
Fax your medical record(s) to us at +1 (503) 584-1269.
Additional Comments

Scheduling

Click on any (+) sign to expand that section

Your Information

Adjuster Information (if applicable)

Claimant Information

Appointment Information

Claimant's Attorney Information

Interpreter Services

Travel Arrangements

Diagnostic Request

Medical Record Delivery