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.
Injured Worker
The employee who has suffered a work-related injury or illness and is seeking benefits.
Claim Information
Documentation details for the claim itself.
Insurance company
The party responsible for reimbursement of the result of the worker’s injury.
Employer Information
The party impacted by the injured worker no longer being able to fulfill their duties as an employee.
Adjuster Information
The agent who handles insurance-related claims, commissioned by the insurance company.
Case Manager
The overseer that ensures claims and expenses are necessary, reasonable, and legitimate.
Referring Physician
The individual who directs the patient for care to the provider rendering the services being reported.
Physical Therapy
The employee who has suffered a work-related injury or illness and is seeking benefits.
    Diagnostics
    The process(es) of evaluating and determining the validity and specifics of a claim related to a work-related injury or illness.
    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.