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Adjuster Information
Name*
First Last
Email*
Phone*
Fax*
Patient / Claimant Information
Patient / Claimant Name*
First Last
Claim No*
Address*
Street Address City State ZIP
Phone*
DOI*
MM
DD
YYYY
DOB*
MM
DD
YYYY
Interpreter
- Yes
- No
Language
Appointment Information
File Review
If the claimant does not show for this appointment, would you like the provider to perform a file review?
- Yes
- No
Exam Type
- Single
- Panel
Specialty Requested
Other
Specialty Requested #1
Other #1
Specialty Requested #2
Other #2
Location
- Washington Locations please check here
Appointment Location
Type of Injury
- Personal Injury
- Worker's Compensation
Parts of the body*
- Medical records are more than one inch thick
- X-rays / diagnostic images
- There will be more than 15 questions on the cover letter
Insurance Company
Address
Street Address City State / Province / Region ZIP / Postal Code
Other Information
Attorney Representation
Address
Street Address City State ZIP Code
Phone
Comments

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Contact Us

Sunrise Medical Consultants, LLC

P.O. Box: 2688
Salem, OR 97308, United States
https://sunrisemed.net
866.391.9911

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Scheduling in

Oregon
Salem, Keizer, Portland, Eugene, Corvallis, Bend, Newport, Pendleton, Ontario

Washington
Vancouver, Olympia, Tacoma, Seattle, Renton, Everett, Bellingham, Silverdale, Port Angeles, Wenatchee, Moses Lake, Yakima, Spokane, Tri-Cities, Walla Walla

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