Referral Process

Referrals can be made by calling or emailing our office, faxing, mailing or contacting the preferred consultant directly.

Once a Referral is received by our office, the consultant will be notified immediately.

Initial reports are written within two weeks of the initial contact with the claimant, then progress reports are written every thirty days.

We offer Flexibility with our accounts. Special handling requests will be accommodated.

Consultants are available to review the files prior to referral if requested.

Please complete the following form in its entirety and return it to our office via fax or mail. 

This form will be web submitable soon.

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Patient Referral Form

Date:        Patient Information: Patient Name   Employee Mailing Address  Employee City, State and Zip  Patient Phone                       Date of Birth (Patient)      Social Security Number     Date of Injury                *Diagnosis Patient Email Employment Information: Employer Name       Employer Contact Employer Mailing Address Employer City, State and Zip  Employee Job Title          Employer Phone                     Employer Fax                            Employer Email                 Billing Information: Referred By         Organization     Billing Mailing Address Billing City, State and Zip  Claim Number               Billing Phone                     Billing Fax                             Billing  Email   Insurer: Primary Insurer Secondary Insurer   Service Required: Medical Case Management Vocational Case Management Medical Cost Estimate Reserve Setting Other         Attorney Information: Name/Organization         Contact    Attorney Mailing Address Attorney City, State and Zip  Attorney Phone                     Attorney Fax                            Attorney  Email   Type of Claim: No Fault Automobile Workman's Compensation Long Term Disability Other     Reporting and Invoicing: Reports mailed to Referring Office Invoices Mailed to Referring Office Both Reports and Invoices Mailed to Referring Office