Referral Form

 

Important: Please do not hit "Enter" or "Submit" until you have completed the form.

Referral Date:
Services Requested:  
 
Bill To:  

Referring Party (Required)

First Name:  
Last Name:  
Company Name:  
Mailing Address:  
City:    State:    Zip:        
Phone:  
Fax:  
Email:
 
 

Injured Worker and Claim Information (Required)

First Name:  
Last Name:  
Gender:  
Mailing Address:
City:    State:    Zip:
Phone:   Age at Injury:
Claim #:  
Jurisdiction:
Please provide the jursidiction where the injured worker's accident occurred. Many states have jurisdiction-specific case handling process requirements.
Date of Injury:
Last Date Worked:
Description of Injury:
ICD10 Code:
The ICD10 code is the injury diagnosis billing code. Please enter the ICD10 code if required by account instructions.
Current Physical Restrictions provided by treating physician or IME:  
IMPORTANT: For Transition2Work referrals, we cannot locate an assignment until we receive this information.
Average Weekly Wage (AWW):
Average Weekly Comp Rate:
Pre-Injury Occupation:
Primary Language:
Knowing language barriers will assist in locating appropriate assignments.
Secondary Language:
Hourly rate of pay while in program (Transition2Work referrals only):
Number of hours per week to schedule while in program (Transition2Work referrals only):
Additional File Information
or Special Instructions (if applicable):

NOTE: If part of a Self Insured Group or Captive Group, please provide group name.
 
 

Insurance Carrier Information

Company Name:

Claims Professional Information

First Name:
Last Name:
Email:
Mailing Address:
City:    State:    Zip:
Phone:
Fax:
 

Employer Information

Company Name:

Employer Contact Information

First Name:
Last Name:
Email:
Mailing Address:
City:    State:    Zip:
Phone:
Fax:
 

Injured Worker's Attorney (if applicable)

IMPORTANT: If the injured worker has legal representation, our staff is required to copy the attorney on correspondence.
First Name:
Last Name:
Firm Name:
Address:
City:    State:    Zip:
Phone:
Fax:
Email:
 

Defense Attorney (if applicable)

If identified, the defense attorney is copied on correspondence.
First Name:
Last Name:
Firm Name:
Address:
City:    State:    Zip:
Phone:
Fax:
Email: