National Coverage with Regional Service Centers   |   
Phone:P: 800.340.4262   |    Fax:F: 800.358.2533   |   
Email: service@certifiedmed.com
inner-banner
 

Service Request

Please fill out the form below to request a service / services needed. We will respond to your request within 24 hours. If you have questions, please contact us at 800.340.4262. Thank you for choosing Certified Medical.

    Indicate the service you need to request. All 2nd opinion exams are to considered an IME for purposes of this request form. A "Re-Exam" is if the doctor has already seen the examinee and a follow up is necessary. "Peer" if you need a review of records performed.
  • This is required so we may send a confirmation to you
  • Only required if you need this indicated on appointment letters and other contact information being sent on your behalf
  • If the insured is the same person as the examinee you do not need to complete this area.
  • Claimant / Examinee information

  • If there is a known ext# , please indicate in other contact information below
  • Drop files here or
  • Attorney info if applicable

National Coverage with
Regional Service Centers

View Full Site