Online Referral - Medex Service

Company Information:

Company Name*

Representative*

Phone Number*

Address*

City*

State*

Zip*

Email Address*

Attorney’s Information:

Attorney Name

Attorney Fax Number

Attorney Phone Number

Attorney Address

Attorney City

Attorney State

Attorney Zip

Claim Information:

Claim Number*

Claimant Name*

Date of Birth*

Date of Loss*

Address*

City*

State*

Zip*

Claimant Phone Number

Claimant Cell Phone Number

Claimant Work Phone Number

Policy Number

Policy Holder

Policy State

Gender:*

Male

Female

Minor:*

Yes

(if yes) Guardian’s name

Treating Provider’s Information:

Provider Name

Specialty

Phone Number

Fax Number

Address

City

State

Zip

Employer Information (Work Comp Cases Only):

Employers Name

Phone Number

Fax Number

Address

City

State

Zip

Additional Claimant Information (Same DOL):

Claim Number

DOL:

Gender:*

Male

Female

Claimant’s Address

Claimant’s City

State

Zip

Policy Number

Policy State

Claimant’s Name

Date of Birth*

Phone Number

Cell Phone

Minor:*

Yes

(if yes) Guardian’s name

Policy Holder

Comments:

Untitled

Service Information:

IME

Peer Review

Radiology

Second Medical Opinion

PIP

MedPay

Disability

Specialty

Transportation:*

Yes

Translation:*

Yes

Language

Auto Reschedule:*

Yes

SERVICE TYPE:

Service Information:

IME

Peer Review

Radiology

Second Medical Opinion

Specialty

ADDITIONAL SERVICE TYPE:

Service Information:

IME

Peer Review

Radiology

Second Medical Opinion

Specialty

Items to address:

Service Information:

Medical Records:

Service Information:

Upload Medical Records

No Medical Records Available

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Accepted file types: jpg, tif, png, pdf, zip, tar, doc, docx, ai, psd, Max. file size: 5 MB.

File

Accepted file types: jpg, tif, png, pdf, zip, tar, doc, docx, ai, psd, Max. file size: 5 MB.

File

Accepted file types: jpg, tif, png, pdf, zip, tar, doc, docx, ai, psd, Max. file size: 5 MB.

File

Accepted file types: jpg, tif, png, pdf, zip, tar, doc, docx, ai, psd, Max. file size: 5 MB.