Step 1 of 9 - Service 11% Hiddenvar-service-type Step 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 Name Title Company Name(Required) Address 1 Address 2 City State Zip Phone(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) Title Carrier Company Address Address 2 City State Zip Phone(Required)Email(Required) Step 4 | ClaimantClaim Number(Required) First Name(Required) Last Name(Required) Address 1(Required) Address 2 City(Required) State(Required) Zip Phone(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 / Time What is the nature of the injury? Step 5 | Employer InsuredName(Required) Address 1 Address 2 City(Required) State Zip Contact Person(Required) Phone(Required)Email Step 6 | Treating PhysicianName(Required) Address 1 Address 2 City(Required) State(Required) Zip Contact Person Phone(Required)Email Step 7 | Plaintiff CounselName(Required) Address 1 Address 2 City(Required) State Zip Contact Person(Required) Phone(Required)Email Step 8 | Defense CounselName(Required) Address 1 Address 2 City(Required) State Zip Contact 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
