ABOUT US
Company Overview
PRODUCTS
Management Services
REFERRAL REQUEST FORM
RME, Designated Doctor & Peer Review
CLIENT LOGIN
Secure Member Access
Referral Request Form
Providing reliable results and solutions since 2000
Home
Pages
Referral Request Form
Referral Request
Please complete the following form and a representative will contact you shortly thereafter. Items marked with
*
are required.
Service and Business Type
*
Service Type:
Please Select
RME
Peer Review
Designated Doctor Request
*
Business Type:
Please Select
Workers Compensation
Liability
Disability
Other
Company Information
*
Company Name:
Address 1:
Address 2:
City:
State:
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip/Postal Code:
Phone:
Client Information
*
First Name:
*
Last Name:
Office:
*
Phone:
Fax:
*
Email:
Claimant Information
*
Claim Number:
*
Date of Injury:
Prefix:
Please Select
Dr.
Mr.
Mrs.
Ms.
Date of Birth:
*
First Name:
*
Last Name:
Address 1:
Address 2:
City:
State:
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip/Postal Code:
Phone/Extension:
Mobile:
Fax:
Email:
Social Security Number:
Gender:
Please Select
Female
Male
State of Loss:
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Translation:
Claimant Attorney
Firm/Attorney Name:
Phone:
Fax:
Email:
Address:
Treating Physician
First Name:
Last Name:
Reason for RME/DD
Select Reason:
Maximum Medical Improvement
Impairment Rating
Extent of Injury
Disability
Return to Work
Other Similar Issues
Appropriateness of Healthcare (RME only)
Other Information
Physician Special Instructions:
Other Comments:
Related Parties
Case Manager Name:
Case Manager Phone:
Case Manager Email:
Defense Attorney Name:
Defense Attorney Phone:
Defense Attorney Email:
Employer Information
Employer:
Address 1:
City:
State:
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip/Postal Code:
Phone/Extension:
Fax:
Email:
Contact First Name:
Contact Last Name:
Submit Request