Step 1 of 9 - Service 11% Hiddenvar-service-type Step 1 | Speciality Services ReferralCase 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 Step 2 | Referred BySubmitted By(Required) Referral Contact Name Title Company Name Address 1 Address 2 City State Zip PhoneEmail Marketing RepresenativeMarketing RepresenativeJessica BogdanBrian HerringAltricia FeltonJack LazurDavid MillerDrew RotzStephanie TaylorEric WhitworthN/A Step 3 | CarrierCarrier is the referral source?(Required) Yes No Carrier InfoCarrier Name Title Carrier Company Address Address 2 City State Zip PhoneEmail Step 4 | ClaimantClaim Number First Name(Required) Last Name(Required) Address 1 Address 2 City State Zip PhoneMobile PhoneEmail Birth Date SSN Primary LanguagePrimary LanguagePrimary LanguageEnglishSpanishOtherIs the claimant represented by and attorney? Yes No Has the claim been accepted? Yes No Unsure Next Appt Date / Time What is the nature of the injury? Step 5 | Employer InsuredName Address 1 Address 2 City State Zip Contact Person PhoneEmail Step 6 | Treating PhysicianName Address 1 Address 2 City State Zip Contact Person PhoneEmail Step 7 | Plaintiff CounselName Address 1 Address 2 City State Zip Contact Person PhoneEmail Step 8 | Defense CounselName Address 1 Address 2 City State Zip Contact Person PhoneEmail 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
