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On-Line Referral Form

To complete this On-Line Referral, enter the information below, then click the submit button. Once we have the information, we'll call you to confirm. If you'd like assistance, please call 1-800-291-4936, extension 3.

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            The enter key will submit this form.

Examinee Information
Name: * (required)
Examinee Phone:
Address:
City:
State:     
ZIP:
Social Security Number: this format please 111-22-3333
Date of Birth:  this format please 08-12-68
Date of injury:
Insured:
Claim Number: * (required)
Treating Physician:
Complaint:
Requests:
Taxi
Certified Mail
Interpreter (If yes, please type the language on the next line)
Language:
Report by Date:
Type of claim:
Workman's Comp
Auto
PIP
Other 

Adjuster Information
Adjuster: * (required)
Company: * (required)
Address:
City:
State:  
Zip:
Phone: * (required)
Extension:
Fax:
Adjuster's e-mail address

Attorney Information
Law Firm:
Attorney
Address:
City:
State:
Zip:
Phone:
Extension:
Fax:

Type of  Evaluation
Please  Choose One  
Exam (IME)
Re-Exam
Rescheduled Exam
Record Review
Bill Audit
Rebuttal
Section 36 Only
Addendum
Other

Physician Specialty
Please  Choose One  
Orthopedic
Chiropractic
Neurological
Neurosurgical
Physical Therapy
Hand Specialist
Internal Medicine
Psychology
Psychiatry
Other 

Letter Sent To
Send appointmentletter to: Adjuster  Examinee  Attorney  Other   

Report Sent To
Send report to: Adjuster  Examinee  Attorney  Other   

Issues to Address
Causal Relationship
History-Prior Condition
Diagnosis
Permanency
Further Treatment Necessary
Total/Partial Disability
Residuals
Medical End Result
Treatment Reasonable and Necessary
Work Capacity
Light Duty Restrictions
Reasonableness of Fees
Additional issues
specific to this claim:
                     

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