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Worker's Compensation

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.

OrthoIndy Workers' Compensation Representatives:

Norette Mason, WC Liaison
Ashley Angleton, WC Assistant
Cari Waggoner, WC Assistant
Marysia Zilka, WC Assistant

Required fields marked with an asterisk (*).

Patient's Name (required)

Adjuster's Billing Zipcode

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

Date of Injury

Body Part Injured

Adjuster's Name (required)

Adjuster's Email

Adjuster's Phone

Adjuster's Fax

Adjuster's Billing Address

Nurse Case Manager On-site
Phone

Nurse Case Manager's Email

Nurse Case Manager's Phone

Nurse Case Manager's Fax

Employee's First & Last Name (required)

Employee's Email

Employee's Phone

Employee's Fax

Employee's Address

Employee's Zipcode

Received Work Status Yes
No

Received Dictation Yes
No

Preferred Appointment Time AM
PM

Preferred Physician

Preferred Location

Comments

Pay My Bill

Refill Prescription

Request Medical Records

OrthoStore

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