Case Management Referral Form

Fields with an asterisk (*) are required.

    Requested By

    TPA/Insurance Co.*:

    Adjuster Name*:

    Phone*:

    Email*:

    Phone (Direct):

    Fax:

    Additional Information

    Case Type:

    Classification*:

    NonsubscriberWork Comp

    State Jurisdiction:

    Special Instructions:

    Employer Information

    Name*:

    Contact Name*:

    Address 1:

    Address 2:

    City:

      State:   Zip: 

    Phone:

    Fax:

    Email:

    Employee Information

    Name*:

    Phone*:

    Date of Birth*:

    Body Part*:

    Email:

    Claim Number:

    Address 1:

    Address 2:

    City:

      State:   Zip: 

    Occupation:

    SSN:

    Date of Hire:

    Date of Injury:

    Accident Description:

    Diagnosis:

    Physician

    Name:

    Phone:

    Address 1:

    Address 2:

    City:

      State:   Zip: 

    Fax:

    Attachment

    Please attach the First Report of Injury (if available). This will help us process your case more efficiently. Must be PDF and max file size is 2MB.

    Or you may fax the First Report of Injury directly to our Referral Fax # 888.225.9087

    Attach Report:

    Verify Submission - You MUST check the box below

    A friendly reminder to verify all the fields, to enable us to address the case quickly.

    I have verified all the fields.