Referral Form

E-mail:     Date of Referral:

Company Information:
Company:
Representative:
Address:
Suite:
City/State/Zip:
Phone:
Fax:
For liability cases cc: Def. Atty:
County Venued:
Defense Firm:
Attorney:
Address:
City/State/Zip:
Phone:
Fax:
   
Claimant Information:
Claim number:
Claimant:
Address:
Apt. #:
City/State/Zip:
Phone:
Insured:
Date of Injury:
SSN/DOB:
Plaintiff Firm
Name:
Address:
City/State/Zip:
Phone:
Fax:
 For Workers Compensation Cases:
ANCR: Treating Doctor:
WCB Number: Address:
WCB Location: City/State/Zip:
 Type of claim:
General Liability: Workers Comp: No-Fault: Disability:
 
 Type of referral:

Initial Examination

Re-examination

Peer/Record Review

Radiology Review   

Carrier has films
       

Obtain films:
(Please fax authorization if available)

Specialty required:
Chiropractor Neurologist Otolaryngologist (ENT) Psychiatrist
Dentist

Neurosurgeon

Physiatrist (PMR) Psychologist
General Surgeon

Ophthalmologist

Plastic Surgeon Pulmonologist
Hand Specialist Orthopedic Surgeon Podiatrist Urologist
Internist Other:
 
Issues to be addressed:
Causal Relationship Maximum Medical Improvement Schedule Loss of Use
Degree of Disability

Need for Treatment

M&S Issues 
Work Restrictions

Frequency/Duration of Treatment

Permanency 
Anticipated Return to Work Need for Testing Prognosis
 
Additional information: