Referral Party Information Referring Source (Adjuster Name) Referring Company Address City State Zip Phone Fax Email* Required for confirmation receipt Bill To Information Same as above Contact Name Referring Company Address City State Zip Phone Fax Email Patient Information Name Address City State Zip Home Phone Work Phone Cell Phone Social Security Date of Birth Employer Occupation Claim Number Date of Injury / Accident Injury Description Other Complaints Currently Working?YesNo Claim Accepted?YesNo Jurisdiction State Type of ClaimChoose OneAutomobileGeneral LiabilityShort Term DisabilityShort Term DisabilityLong Term DisabilityWorkers' CompensationOther Patient Attorney Information Is the patient represented?YesNo Attorney Name Firm Name Address City State Zip Phone Fax Defense Attorney Information Is the defense attorney assigned?YesNo Attorney Name Firm Name Address City State Zip Phone Issues to be Addressed Separate cover letter to followHistory of injury and subsequent treatmentPrior injuries and/or pre-existing conditionsPresent statusIs current treatment reasonable and necessary?Other Appointment Information SpecialtyChoose OneAllergyAnesthesiologyChiropracticCritical Care/TraumaDentistryEar, Nose, ThroatEndocrinologyFamily PracticeGastro IntestinalGeneral SurgeryHematologyInternal MedicineNeurologyNeuropsychologyNeurosurgeryOccupational MedicineOccupational TherapyOral SurgeryOrthopaedic SurgeryOtherPain ManagementPhysiatryPhysical TherapyPlastic SurgeryPsychiatryPsychologyVascular Surgery Specialty (Other) Requested Examiner's Name (Optional) Treating Physicians Provider Under Review (Name) Address City State Zip Phone Fax Email Secondary Provider Address City State Zip Phone Fax Email Secondary Provider Address City State Zip Phone Fax Email Secondary Provider Address City State Zip Phone Fax Email Medical Records Are the records available?YesNo Delivery MethodMailEmailFaxCSG PickupOther Other Delivery Method Notification of Appointment Send Appointment Letter to PatientCopy to Claimant's AttorneyCopy to Defense AttorneyCopy to Referring PartyCopy to Billing Party
Referral Party Information Referring Source (Adjuster Name) Referring Company Address City State Zip Phone Fax Email* Required for confirmation receipt
Bill To Information Same as above Contact Name Referring Company Address City State Zip Phone Fax Email
Patient Information Name Address City State Zip Home Phone Work Phone Cell Phone Social Security Date of Birth Employer Occupation Claim Number Date of Injury / Accident Injury Description Other Complaints Currently Working?YesNo Claim Accepted?YesNo Jurisdiction State Type of ClaimChoose OneAutomobileGeneral LiabilityShort Term DisabilityShort Term DisabilityLong Term DisabilityWorkers' CompensationOther
Patient Attorney Information Is the patient represented?YesNo Attorney Name Firm Name Address City State Zip Phone Fax
Defense Attorney Information Is the defense attorney assigned?YesNo Attorney Name Firm Name Address City State Zip Phone
Issues to be Addressed Separate cover letter to followHistory of injury and subsequent treatmentPrior injuries and/or pre-existing conditionsPresent statusIs current treatment reasonable and necessary?Other
Appointment Information SpecialtyChoose OneAllergyAnesthesiologyChiropracticCritical Care/TraumaDentistryEar, Nose, ThroatEndocrinologyFamily PracticeGastro IntestinalGeneral SurgeryHematologyInternal MedicineNeurologyNeuropsychologyNeurosurgeryOccupational MedicineOccupational TherapyOral SurgeryOrthopaedic SurgeryOtherPain ManagementPhysiatryPhysical TherapyPlastic SurgeryPsychiatryPsychologyVascular Surgery Specialty (Other) Requested Examiner's Name (Optional)
Treating Physicians Provider Under Review (Name) Address City State Zip Phone Fax Email Secondary Provider Address City State Zip Phone Fax Email Secondary Provider Address City State Zip Phone Fax Email Secondary Provider Address City State Zip Phone Fax Email
Medical Records Are the records available?YesNo Delivery MethodMailEmailFaxCSG PickupOther Other Delivery Method
Notification of Appointment Send Appointment Letter to PatientCopy to Claimant's AttorneyCopy to Defense AttorneyCopy to Referring PartyCopy to Billing Party
