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To request an appointment for an employee, please fill out the form below.

When an employee is injured on the job, the physicians of OrthoIndy are here to accurately diagnose and treat the work-related injury. If you are in the worker’s compensation community and have questions, please contact one of the following representatives below or fill out the following form to refer a patient.

Questions? Please call 317-802-2442 to speak to an OrthoIndy Worker's Compensation Representative:

Ashley Angleton
Amber Littell
Kimberley Simmons
Cari Waggoner
Marysia Zilka
Shawn Miller

You can also speak with a Senior Worker's Compensation Specialist:

Norette Mason: 317-268 3197
Tharron Daniels: 317-802-3248
Doug Miller, Director of Business Partnerships: 317-802-2020

Required fields marked with an asterisk (*).

Out-of-State Work Comp Patient Service Agreements: Please click the link to the Hospital insurance agreement or the Clinic insurance agreement, depending on your care needs.

Patient's Name (required)

(required)

Please enter the Patient's Name.

Adjuster's Billing Zipcode

Birth Date (xx/xx/xxxx) (required)

(required)

Please enter the Birth Date (xx/xx/xxxx).

Date of Injury (required)

(required)

Please enter the Date of Injury.

Body Part Injured (required)

(required)

Please enter the Body Part Injured.

Previous Treatment of Injury (ER, etc.) Please enter the Previous Treatment of Injury (ER, etc.).Yes
No

Adjuster's Name (required)

(required)

Please enter the Adjuster's Name.

Adjuster's Email Please enter the Adjuster's Email.

Adjuster's Phone Please enter the Adjuster's Phone.

Adjuster's Fax Please enter the Adjuster's Fax.

Adjuster's Billing Address

Nurse Case Manager Please enter the Nurse Case Manager.On-site
Phone

Nurse Case Manager's Email Please enter the Nurse Case Manager's Email.

Nurse Case Manager's Phone Please enter the Nurse Case Manager's Phone.

Nurse Case Manager's Fax Please enter the Nurse Case Manager's Fax.

Employee's First & Last Name (required)

(required)

Please enter the Employee's First & Last Name.

Employee's Email Please enter the Employee's Email.

Employee's Phone Please enter the Employee's Phone.

Employee's Fax Please enter the Employee's Fax.

Employee's Address

Employee's Zipcode

Received Work Status Please enter the Received Work Status.Yes
No

Received Dictation Please enter the Received Dictation.Yes
No

Preferred Appointment Time Please enter the Preferred Appointment Time.AM
PM

Preferred Physician

Preferred Location

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