REFERRAL FORM




Referrals can be made by calling our office, faxing, mailing, e-mailing, or contacting the preferred consultant directly. Once a referrral is received the consultant will be notified within 24 hours. Initial reports are written within two weeks of the initial cotact with the claimant, and then progress reports are done every 30 days. We offer flexibility with our accounts to provide special handling requests such as more or less frequent reporting intervals, etc.
Client Name:

Address:

City:

State:

Zip:

Phone:

D.O.B.:

SS#:

D.O.I.:

Diagnosis:



Employer:

Address:

City:

State:

Zip:

Phone:

Contact Person:


Insurance Information:
Company:

Adjuster:

Address:

City:

State:

Zip:

Phone:

Fax:

Email:

Claim #:



Coverage:
Auto No Fault
Coordinated Benefits

Workers' Comp

Type of Referral
Medical
Vocational
Assigned
Direct
Consultant


Contacts:(Check all that apply)
Assignment
Limited Assignment
Client Contact
Employer Contact
Physician
Other


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