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Our Physicians

PPG Physicians in

MARYLAND

ppg physicians in

ILLINOIS
Locations

PPG Locations in

MARYLAND

PPG Locations in

ILLINOIS
Services
Forms
- Patient Intake Form
- IME Appointment Request Form
Contact Us

Home

/

Contact Us

Contact one of our main offices or complete
the form below to schedule an appointment

800.910.6139

Toll Free

info@ppgime.com

Email

Office Hours

Monday - Friday
8 AM to 5 PM EST

MARYLAND

410.205.9403

Phone

410.970.4670

Fax

5308 Weywood Dr. Reisterstown, MD 21136

Address

ILLINOIS

773.672.2025

Phone

773.672.2025

Fax

3712 N. Broadway
Chicago, IL
60613

Address

Form Type*
- IME Appointment Request
- Impairing Rating Request
- IME with IR Request
- IME Re-evaluation
- Chart Review
- Second Opinion
- Long & Short Term Disability
- FMLA
Patient Information
Name*
First Last
SSN
Birth Date*
MM slash DD slash YYYY
Current Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Is Patient English Speaking?*
- Yes
- No
Claim Number*
Injury Date*
MM slash DD slash YYYY
Injury(s)
Treating Physician Full Name
XRays must be PreAuthorized*
- Yes
Scheduling Period
Impairment Rating
- One Body Part
- Two Body Parts
- Three Body Parts
- Four or More Body Parts
- Upper Extremity
- Lower Extremity
- Spine/Pelvis
Request Provider*
- Yes
- No
If Yes, Provider Name
Special Instructions
Referral Info
Referral Name*
Send Referral Email Confirmation to*
Referral Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Referral Phone*
Payor Information
Payor Name
Send Payor Email Confirmation to*
Payor Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Payor Phone*
Payment Terms*
- Pre-Pay
- Post-Pay

Please note: Completing this form does not guarantee an appointment date or time. Our staff will contact you to discuss your needs and schedule an appointment.

Patient Intake Form

System Login

Contact Us

800.910.6139

info@ppgime.com

Mon-Fri: 8:00 – 5:00 EST

PPG Physicians in

MARYLAND

ppg physicians in

ILLINOIS

PPG Locations in

MARYLAND

PPG Locations in

ILLINOIS

Contact one of our main offices or complete the form below to schedule an appointment

800.910.6139

info@ppgime.com

Office Hours

Monday - Friday 8 AM to 5 PM EST

MARYLAND

410.205.9403

410.970.4670

5308 Weywood Dr. Reisterstown, MD 21136

ILLINOIS

773.672.2025

773.672.2025

3712 N. BroadwayChicago, IL 60613

Patient Information

Referral Info

Payor Information

Contact Us

Contact one of our main offices or complete
the form below to schedule an appointment

Monday - Friday
8 AM to 5 PM EST

3712 N. Broadway
Chicago, IL
60613