info@aimcminc.com | (717) 239-0500 | (866) 308-9600 | Case Manager Access

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Service Request

To learn more about how Alliance Impairment Management can meet your case management needs, please contact us using the information at the right or complete our Service Request Form below.

Contact Details

1. Claims Examiner:
2. Telephone:
3. Referral Source:
4. Fax:
5. Address:
6. City:
7. State:
8. Zip Code:
9. Defense Attorney:
10. Address:
11. Telephone:
12. Fax:

Employee Information

1. Name:
2. Claim #:
3. County:
4. Address:
5. City:
6. State:
7. Zip Code:
8. Telephone:
9. DOI:
10. Date of Birth:
11. Occupation:
12. Plantiff Attorney:
13. Telephone:
14. Address:
15. Physician:
16. Diagnosis:

Employer Information

1. Employer:
2. Contact Person:
3. Address:
4. City:
5. State:
6. Zip Code:
7. Telephone:
8. Fax:
9. Email:

Referral Information

1. Services Requested:

   1. Medical Case Management
   2. Medical Reserve Analysis/Medical Bill Audits
   3. Life Care Planning
   4. IME Coordination
   5. Earning Power Assessment
   6. File Review
   7. Medicare Set-Aside
   8. LTD Case Management
   9. Long Term Care Case Management
   10. Other:  

   
   
2. Special Instructions:

Submit Service Request

Contact Us

Mailing Address:
PO Box 1557
Lancaster PA 17608-1557

Telephone:
(717) 239-0500
(866) 308-9600

Fax:
(717) 239-0660

info@aimcminc.com | (717) 239-0500 | (866) 308-9600

• Home
• About AIM
• Services
• Partners
• Request Info