Pro+Referral Party InformationReferring Source (Adjuster Name)Referring CompanyAddressAddress Line 1CityStateZip CodePhoneFaxEmailBill To InformationContact NameReferring CompanyAddressAddress Line 1CityStateZip CodePhoneFaxEmailPatient InformationNameAddressAddress Line 1CityStateZip CodeHome PhoneWork PhoneCell PhoneSocial SecurityDate of BirthEmployerOccupationClaim NumberDate of Injury / AccidentInjury DescriptionOther ComplaintsCurrently Working? Yes NoClaim Accepted? Yes NoJurisdiction StateType of Claim- Select -AutomobileGeneral LiabilityShort Term DisabilityLong Term DisabilityWorker's CompensationOtherPatient Attorney InformationIs the patient represented? Yes NoAttorney NameFirm NameAddressAddress Line 1CityStateZip CodePhoneFaxDefense Attorney InformationIs the defense attorney assigned? Yes NoAttorney NameFirm NameAddressAddress Line 1CityStateZip CodePhoneIssues to be Addressed Separate cover letter to follow History of injury and subsequent treatment Prior injuries and/or pre-existing conditions Present status Is current treatment reasonable and necessary? OtherAppointment InformationSpecialty- Select -AllergyAnesthesiologyChiropracticCritical Care/TraumaDentistryEar, Nose, ThroatEndocrinologyFamily PracticeGastro IntestinalGeneral SurgeryHematologyInternal MedicineNeurologyNeuropsychologyNeurosurgeryOccupational MedicineOccupational TherapyOral SurgeryOrthopedic SurgeryOtherPain ManagementPhysiatryPhysical TherapyPlastic SurgeryPsychiatryPsychologyVascular SurgerySpecialty (Other)Requested Examiner's Name (Optional)Treating PhysiciansProvider Under Review (Name)AddressAddress Line 1CityStateZip CodePhoneFaxEmailSecondary ProviderAddressAddress Line 1CityStateZip CodePhoneFaxEmailSecondary ProviderAddressAddress Line 1CityStateZip CodePhoneFaxEmailSecondary ProviderAddressAddress Line 1CityStateZip CodePhoneFaxEmailMedical RecordsAre the records available? Yes NoDropdown- Select -MailEmailFaxCSG PickupOtherOther Delivery MethodNotification of Appointment Send Appointment Letter to Patient Copy to Claimant's Attorney Copy to Defense Attorney Copy to Referring Party Copy to Billing PartySubmit Form
