Submit Your Referral

Please complete the secure referral form below. Our team will review your submission and contact you as soon as possible.

Who are you submitting this referral as? *

Law Office / Case Manager / Referral Agency

Referring Medical Office

Patient / Self Referral

Do you already have completed referral documents ready to upload?

Yes, I already have completed referral forms/documents

No, I need to complete the referral form online

Is this claim

Accepted Worker's Compensation

Denied Worker's Compensation

Pending/Admitted

Expert Witness

Personal Injury

Does this appointment have to be on the MPN

Yes

No

Company / Law Office Name

Medical Office Name

Is appointment urgent?

Yes

No

Person Requesting Information

Referral Contact Phone

Email or Fax

Adjustor

Adjustor Phone

Need PTP?

Yes

No

Existing PTP

Reason for Referral

Specialty Requested

Osteopathic Medicine

Chiropractic Care

Acupuncture

Pain Management

Vascular Surgery

Dermatology

Plastic Surgery

Podiatry

Orthopedic Surgery

Psychiatry

Neurology

Family Medicine

Injured Body Parts

Diagnosis or Symptoms

Date of Injury

Client/Patient Information

Client/Patient Name

Client/Patient Phone

Insurance Carrier

Employer

MPN

SS#

Client/Patient Home Address

Client/Patient Date of birth

Please upload all necessary documents here

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Doctor Office Information

The mentioned attorney's office/or Carrier/Claims Examiner is seeking areas of potential investigation/issues of concern and we are requesting an appointment for the injured worker. If additional information is needed: contact the person requesting information. Please make any secondary appointments.

Attention

Doctor

Appointment Date/Time

Office Address

Doctor Office Phone

Doctor Office Fax Number

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