Online Referral

Company Information:

*Company's Name

*Representative

*Phone Number

*Address

*City

*State/Zip

*Email Address

Attorney’s Information:

Attorney’s Name

Attorneys Phone Number

Attorney’s Fax Number

Attorney Address

Attorney’s City

Attornye's State/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: MaleFemale

Minor: YesNo

(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: MaleFemale

Claimant’s Address

Claimant’s City

State/Zip

Policy Number

Policy State

Claimant’s Name

Date of Birth

Phone Number

Cell Phone

Minor: YesNo

(if yes) Guardian’s name

Policy Holder

Comments:

ADDITIONAL SERVICE TYPE:

SERVICE TYPE:

IMEPeer ReviewRadiology ReviewSecond Medical Opinion

Specialty

Additional Service Type:

IMEPeer ReviewRadiology ReviewSecond Medical Opinion

Specialty

Items to address:

Medical Records:

Upload Medical RecordsNo Medical Records Available

Company Information:

Attorney’s Information:

Claim Information:

Treating Provider’s Information:

Employer Information (Work Comp Cases Only):

Additional Claimant Information (Same DOL):

Comments:

Service Information:

ADDITIONAL SERVICE TYPE:

SERVICE TYPE:

Additional Service Type:

Items to address:

Medical Records: