National Coverage with Regional Service Centers   |   
Phone:P: 800.340.4262   |    Fax:F: 800.358.2533   |   

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.
  • Max. file size: 128 MB.
  • 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

  • MM slash DD slash YYYY
  • If there is a known ext# , please indicate in other contact information below
  • Drop files here or
    Max. file size: 128 MB.
    • Attorney info if applicable

    National Coverage with
    Regional Service Centers

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