Workers Compensation Appointment Request

Ahead of the curve

Thank you for choosing OrthoArkansas for the treatment of your injured worker. OrthoArkansas looks forward to providing the utmost care to the patient as well as providing clear and timely communication with the scheduling party.

To request an appointment for an injured worker or to send injured worker to one of our urgent care locations, please complete and submit the form below.

Three convenient, walk-in
Urgent Care locations:

OrthoArkansas-Midtown
800 Fair Park Blvd.
Little Rock, AR 72204

OrthoArkansas-North Little Rock
3480 Landers Rd.
North Little Rock, AR 72117

OrthoArkansas-Conway
505 E. Dave Ward Dr. Ste B.
Conway, AR 72032

Contact Workers’ Compensation Team

Phone: 501-500-1750
Email: workcomp@orthoarkansas.com

Name

Patient Date of Birth

Patient Address

Patient Phone Number

Insurance Carrier

Carrier Billing Address

Date of Injury

Claim number

Body Part Injured

Employer

Adjuster Name

Adjuster Phone Number

Adjuster Email

Adjuster Fax

Nurse Case Manager Name

Nurse Case Manager Phone Number

Nurse Case Manager Email

Nurse Case Manager Fax

Will this be an urgent care visit? If yes, please choose location.

Prefered appointment time

Preferred Location

If you have a provider preference, please list in the space below.

Will interpreter services be needed for this patient?

Yes No

Additional information (if needed)

Workers Compensation Appointment Request

Three convenient, walk-inUrgent Care locations:

Contact Workers’ Compensation Team

Three convenient, walk-in
Urgent Care locations: