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 Claim Choose 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
Treating Physicians Provider Under Review (Name) Medical Specialty Specialty Choose OneAllergyAnesthesiologyChiropracticCritical Care/TraumaDentistryEar, Nose, ThroatEndocrinologyFamily PracticeGastro IntestinalGeneral SurgeryHematologyInternal MedicineNeurologyNeuropsychologyNeurosurgeryOccupational MedicineOccupational TherapyOral SurgeryOrthopaedic SurgeryOtherPain ManagementPhysiatryPhysical TherapyPlastic SurgeryPsychiatryPsychologyVascular Surgery Specialty (Other) 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 Method MailEmailFaxCSG PickupOther Other Delivery Method