DOWNLOAD
     
     
  For MAC and Windows Operation: PDF Reader Version (at least version 8)
           
 
Steps to Follow:
1) Download the PDF file
 

2) You may complete the form on the screen and save it on your PC

  3) You should print the completed form BEFORE closing it
  4) After printing the completed form, you can either email, mail or fax the form to us
           
 

Email: registration@aclmd.com
Mail: 1815 N Capitol Ave, Ste 600, Indianapolis, IN 46239
Fax: 317.921.0237

         
     
  New Patient Package
           
 
Map
     
           
  Worker Comp/Motor Vehicle Accident Claims/Litigated Cases
Policies
 
  For Windows Operation: MS Word XP Version  
           
 
Steps to Follow:
1) Download the MS Word Form
 

2) You may complete the form and save the completed file on your hard drive.

  3) You may send the electronic file via email to registration@aclmd.com OR either mail or fax the form to us
     
    New Patient Package
 
  Worker Comp/Motor Vehicle Accident Claims/Litigated Cases
Policies