Step 1 of 9 - Service 11% This field is hidden when viewing the formvar-service-typeStep 1 | Case Management(Required) Field Case Management Telephonic Case Management Catastrophic Case Management Job Analysis Vocational Case Management Bilingual Case Management Earning Power Assessment/Labor Market Survey Specialty Services(Required) Medicare Set-Asides (MSA) Legal File Review Services Life Care Plans RN Record Review Medical Cost Projection Medical/Vocational Expert Services Triage Desensitization Services Previous Page Step 2 | Referred BySubmitted By(Required)Referral Contact NameTitleCompany Name(Required)Address 1Address 2CityStateZipPhone(Required)Email(Required) Marketing RepresenativeMarketing RepresenativeAltricia FeltonJack LazurDavid MillerDrew RotzStephanie TaylorEric WhitworthChelsea CastilloKyle BrouilletteKyle StoyN/A Step 3 | CarrierCarrier is the referral source?(Required) Yes No Carrier InfoCarrier Name(Required)TitleCarrier CompanyAddressAddress 2CityStateZipPhone(Required)Email(Required) Step 4 | ClaimantClaim Number(Required)First Name(Required)Last Name(Required)Address 1(Required)Address 2City(Required)State(Required)ZipPhone(Required)Mobile PhoneEmail Birth Date(Required)SSN(Required)Primary LanguagePrimary LanguagePrimary LanguageEnglishSpanishOtherIs the claimant represented by and attorney?(Required) Yes No Has the claim been accepted?(Required) Yes No Unsure Next Appt Date / TimeWhat is the nature of the injury? Step 5 | Employer InsuredName(Required)Address 1Address 2City(Required)StateZipContact Person(Required)Phone(Required)Email Step 6 | Treating PhysicianName(Required)Address 1Address 2City(Required)State(Required)ZipContact PersonPhone(Required)Email Step 7 | Plaintiff CounselName(Required)Address 1Address 2City(Required)StateZipContact Person(Required)Phone(Required)Email Step 8 | Defense CounselName(Required)Address 1Address 2City(Required)StateZipContact Person(Required)Phone(Required)Email Step 9 | Upload RecordsNotes or CommentsFile(Note: Individual attachments larger than 5MB (15MB total) cannot be accepted, please contact us for larger referrals.) Drop files here or Select files Max. file size: 50 MB. CAPTCHA
