Referral Form

E-mail:     Date of Referral:

Company Information: Claimant Information:
Company: Claim number:
Representative: Claimant:
Address: Address:
Suite: Apt. #:
City/State/Zip: City/State/Zip:
Phone: Phone:
Fax: Insured:
For liability cases cc: Def. Atty: Date of Injury:
County Venued: SSN/DOB:
Defense Firm: Plaintiff Firm
Attorney: Name:
Address: Address:
City/State/Zip: City/State/Zip:
Phone: Phone:
Fax: Fax:
 For Workers Compensation Cases:
ANCR: Treating Doctor:
WCB Number: Address:
WCB Location: City/State/Zip:
 Type of claim:
General Liability: Workers Comp: No-Fault: Disability:
 
 Type of referral:

Initial Examination

Re-examination

Peer/Record Review

Radiology Review   

Carrier has films
       

Obtain films:
(Please fax authorization if available)

Specialty required:
Chiropractor Neurologist Otolaryngologist (ENT) Psychiatrist
Dentist

Neurosurgeon

Physiatrist (PMR) Psychologist
General Surgeon

Ophthalmologist

 Plastic Surgeon Pulmonologist
Hand Specialist Orthopedic Surgeon Podiatrist Urologist
Internist Other:
 
Issues to be addressed:
Causal Relationship Maximum Medical Improvement Schedule Loss of Use
Degree of Disability

Need for Treatment

 M&S Issues 
Work Restrictions

Frequency/Duration of Treatment

 Permanency 
Anticipated Return to Work Need for Testing Prognosis
 
Additional information: