Web Referral - StreamlineWorkComp.com

Submit Referral

Please complete the form below. If you have the order for the procedure please fax it to 904-944-4176. At the very least we need the claimant's: Name, Date of Birth, Address, Phone#, Date of Injury, Claim#, Referring Physician Name & Phone#, Procedure Being Ordered, Adjuster Name and Email.

Submitter Name The referrer of this case.

Submitter Email The email of the submitter of this case.

Carrier The carrier of this case.

Payor The payor (if different from the carrier).

Claim Number The claim number of this case.

Claimant DOI The claimant's date of injury.

First Report Of Injury Attached

Claimant First Name The claimant's first name.

Claimant Last Name The claimant's last name.

Claimant DOB The claimant's date of birth.

Claimant SSN Last 4 The claimant's last 4 SSN.

Claimant Address The claimant's address.

Claimant Address 2 The claimant's address (line 2).

Claimant City The claimant's city.

Claimant State The claimant's state.

Claimant Zip The claimant's zip code.

Claimant Cell Phone The claimant's cell phone number.

Claimant Home Phone The claimant's home phone number.

Claimant Employer The claimant's employer.

Claimant Jurisdiction The claimant's jurisdiction.

ASAP

Spanish Speaking

Script Faxed

Script Emailed

Referring Physician First Name The referring physician's first name.

Referring Physician Last Name The referring physician's last name.

Referring Physician Phone The referring physician's phone number.

Adjuster First Name The adjuster's first name.

Adjuster Last Name The adjuster's last name.

Adjuster Email The adjuster's email.

Case Manager First Name The case manager's first name.

Case Manager Last Name The case manager's last name.

Case Manager Email The case manager's email.

Tests Ordered Please enter tests ordered.

Therapy Type Select the physical therapy type.

Therapy Type Other Description Please enter other therapy type.

Body Part Select the body part.

Body Part Side Select the body part side.

Injury Type Select the injury type.

Frequency / Duration / Visits Authorized Enter the frequency / duration / visits authorized.

Special Instructions Additional notes.

Drop Files Here

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To add files to this referral, either drag and drop them into this box, or click anywhere inside the box to open a file dialog.