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Referral Draft - Standard Referral
Referral Draft - Standard Referral
Services Requested
Transition2Work for Workers' Compensation claim
Transition2Work for non-occupational disability
Campaign
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Referring Party
Your Affiliation
Carrier
TPA
Employer
SIG (Self Insured Group)
Nurse Case Manager
Broker
Other
Your Company
*
First Name
*
Last Name
*
Email Address
*
Mailing Address
*
City
*
State
*
Zip Code
*
Phone
*
Fax
*
SCIF Claims Office
Bakersfield (NT)
Fresno (NE)
Los Angeles (SA) [Includes CBA]
Major Claims Operation - Insured (SG)
Major Claims Operation – State Contracts (TX)
Pleasanton (NA) [Includes L&H]
Redding (NJ)
Riverside (SK)
Santa Ana Insured (SP)
Stockton (NK)
State Contracts - Eureka (NH)
State Contracts - Santa Ana (TN)
State Contracts - Riverside (TQ)
State Contracts - Rohnert Park (TY)
State Contracts - Sacramento (TL)
State Contracts - Vacavaille (NC)
ESIS Office AIM
*
*
Is this a DSP?
Is this a DSP?
No
Is this a DSP?
Yes
Injured Worker and Claim Information
First Name
*
Last Name
*
Claim Number
*
Gender
*
Mailing Address
*
Suite/Apt
*
City
*
State
*
Zip Code
*
Physical Address is the same as Mailing Address
Yes
No
Physical Address
*
Suite/Apt
*
City
*
State
*
Zip Code
*
Phone
*
Email Address
*
*
State/Jurisdiction
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX Non-subscriber
TX Subscriber
UT
VA
VT
WA
WI
WV
WY
Date of Injury
*
Pre-Injury Occupation
*
Description of Injury
*
Current Physical Restrictions provided by a treating physician
*
Average Weekly Wage (AWW)
*
Average Weekly Comp Rate
*
Primary Language
*
Secondary Language
*
Hourly Rate of Pay Employer will Pay while in Transition2Work
*
Is the Injured Worker a Union Member?
Yes
No
Unknown
Standard assignments are 32-40 hours per week. Check this box only if other hours are required.
Number of Hours per Week to Schedule while in Transition2Work
*
Standard schedules are 7A-7P, Mon-Sat. Check this box only if a different schedule is required.
Schedule Details Required While in Transition2Work
*
Which location would you like the injured worker to work light duty?
At the nonprofit’s physical location
Working from home on assigned nonprofit duties
Working from the employer’s worksite on assigned nonprofit duties
Special Accommodations (ie. deaf or hard of hearing, crutches, unrelated injury, etc.)
*
Additional File Information (ie. instructions, PT schedule, appointments, transportation, etc.)
*
Employee ID (Optional)
*
Disability Details
Date of Disability
*
Description of Disability
*
Claims Professional Information
Use My Contact Information
Use My Contact Information
No
Use My Contact Information
Yes
Insurance Carrier | Company Name
*
Email
*
*
First Name
*
Last Name
*
Mailing Address
*
City
*
State
*
Zip Code
*
Phone
*
Fax
*
Employer Information
Use My Contact Information
Use My Contact Information
No
Use My Contact Information
Yes
Employer | Company Name
*
Email
*
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip
*
Phone
*
Fax
*
Is this employer part of a Self-Insured Group?
Is this employer part of a Self-Insured Group?
No
Is this employer part of a Self-Insured Group?
Yes
Please List
*
Risk Analyst Information
Risk Analyst | Company Name
*
Email
*
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip
*
Phone
*
Fax
*
Litigation Information
Is there attorney involvement on this claim?
Yes
No
Unknown
Defense Attorney Information
Defense Attorney Law Firm
*
First Name
*
Last Name
*
Email
*
Mailing Address
*
City
*
State
*
Zip Code
*
Phone
*
Fax
*
Is the injured worker represented by an attorney ?
Yes
No
Unknown
Injured Worker’s Attorney Information
Injured Worker Attorney Law Firm
*
First Name
*
Last Name
*
Email
*
Mailing Address
*
City
*
State
*
Zip Code
*
Phone
*
Fax
*
Physician Information
Medical Office
*
First Name
*
Last Name
*
Mailing Address
*
City
*
State
*
Zip
*
Phone
*
Fax
*
By submitting this referral, you acknowledge and accept our pricing guidelines and service fees. Invoices are submitted to the insurance carrier or TPA unless otherwise indicated.
I understand the pricing guidelines and service fees.
I have questions about the pricing guidelines and/or service fees.
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