Referral Form

To submit a new referral, please complete the form below and click 'Submit'.

Services Requested

Bill To

Referring Party (Required)

Affiliation

Company Name

Name

Mailing Address

City

State

Zip

Phone

Fax

Injured Worker and Claim Information (Required)

First Name

Last Name

Claim Number

Gender

Mailing Address

City

State

Zip

Physical Address (if different from Mailing Address)

City

State

Zip

Phone

State/Jurisdiction of Injury

Pre-Injury Occupation

Age at Injury

Last Date of Work

Date of Injury

ICD10 Code

Description of Injury

Current Physical Restrictions provided by a treating physician or IME

AWW ($)

Comp Rate ($)

Primary Language

Secondary Language

T2W Hourly Rate of Pay

T2W Hours/Week and Preferred Schedule

Which location would you like the employee/claimant to work light duty?

Additional File Information or Special Instructions

Employee ID (optional)

Claims Professional Information

Use My Contact Information

NoYes

Insurance Carrier | Company Name

First Name

Last Name

Mailing Address

City

State

Zip

Phone

Fax

Employer Information

Use My Contact Information

NoYes

Employer | Company Name

Employer | Parent Account

First Name

Last Name

Mailing Address

City

State

Zip

Phone

Fax

Captive Program or Self-Insured Group?

NoYes

Captive Program or Self-Insured Group Name

Injured Worker's Attorney (if applicable)

Law Firm

First Name

Last Name

Mailing Address

City

State

Zip

Phone

Fax

Defense Attorney (if applicable)

Law Firm

First Name

Last Name

Mailing Address

City

State

Zip

Phone

Fax

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Contact Us: 866-663-9880

To submit a new referral, please complete the form below and click 'Submit'.

Referring Party (Required)

Injured Worker and Claim Information (Required)

Claims Professional Information

Employer Information

Injured Worker's Attorney (if applicable)

Defense Attorney (if applicable)