Web Referral - StreamlineWorkComp.com

Please fill out as much of this form as possible. We will follow up with you if any additional information is needed.

Submitter

The person requesting on behalf of the injured worker.

Submitter Type

First Name

Last Name

Office Phone

Ext.

Fax

Email Address

Injured Worker

The employee who has suffered a work-related injury or illness and is seeking benefits.

First Name

Last Name

Gender

Home Phone

Cell Phone

Email Address

Date Of Birth

SSN

Height

Weight

Language

Address

Address 2

City

State

Zip

Claim Information

Documentation details for the claim itself.

Claim Number

Injury/Jurisdiction State

Date Of Injury

Work Status

Insurance company

The party responsible for reimbursement of the result of the worker’s injury.

Name

Phone

Address

Address 2

City

State

Zip

Employer Information

The party impacted by the injured worker no longer being able to fulfill their duties as an employee.

Name

Phone

Address

Address 2

City

State

Zip

Adjuster Information

The agent who handles insurance-related claims, commissioned by the insurance company.

First Name

Last Name

Email Address

Office Phone

Ext.

Fax

Case Manager

The overseer that ensures claims and expenses are necessary, reasonable, and legitimate.

First Name

Last Name

Email Address

Office Phone

Ext.

Fax

Referring Physician

The individual who directs the patient for care to the provider rendering the services being reported.

First Name

Last Name

Email Address

Office Phone

Ext.

Fax

NPI

Physical Therapy

The employee who has suffered a work-related injury or illness and is seeking benefits.

Service Type

Frequency

Duration

Authorized Visits

Surgery Date

Is Rush

Body Part

Body Side

Diagnostics

The process(es) of evaluating and determining the validity and specifics of a claim related to a work-related injury or illness.

Modality

Body Part

Body Side

Is Rush?

Additional information

Special instructions or related notes.

Documents

The employee who has suffered a work-related injury or illness and is seeking benefits.

Drop files here or click inside the box

To add files to this referral, either drag and drop them into this box, or click inside the box to browse your computer.

Please fill out as much of this form as possible.

We will follow up with you if any additional information is needed.