PMSI Mail Order Enrollment Form
Claimant Information
*
Claimant Name:
*
Social Security Number:
*
Phone Number:
*
Address:
*
City:
*
State:
AK
AL
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
*
Zip Code:
*
Date of Injury:
*
Claim Number:
Date of Birth:
Claimant Email:
Referral Information
Referral Contact:
Referral Contact Phone Number:
Referral Contact Email:
Doctor Information
Dr. Name:
Dr. Address:
Dr. City:
Dr. State:
AK
AL
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Dr. Zip Code:
Dr. Phone Number:
Adjuster Information
Adjuster:
Adjuster Phone Number:
Adjuster Email:
Carrier/Payer & Code:
Address:
Employer & Location:
Diagnosis/ICD9 #1:
Diagnosis/ICD9 #2:
Medications Authorized:
Comments or Special Instructions:
If you have any questions please contact PMSI Mail Order Service at 800.304.1764 from 8:30 a.m. to 8:00 p.m. ET.