Innovative Claims Strategies | Service Referral Form

Other (please specify)

Referral Date:*

Referred By*

Claimant/Injured Worker Last Name*

Claimant/Injured Worker First Name*

M.I.

Claimant/Injured Worker's Address*

Address Line 2

City*

State*

ZIP*

Phone

SSN:

Employer:

Employee ID:

Claim Number:*

Date of Birth:*

Date of Injury:*

Occupation:

ATTENDING PHYSICIAN

Attending Physician:

ACCOUNT INFORMATION

Client:*

Assigned Claims Adjuster:*

Adjuster Phone Number

Adjuster Email Address*

Defense Attorney Name:

Attorney Email Address

Attorney Phone Number

Plaintiff Attorney Name:

Attorney Email Address

Attorney Phone Number

Primary Diagnosis Code and Description

SPECIAL INSTRUCTIONS & NOTES

SPECIFIC CLAIM DIRECTIVES

Upload File

Drop files here or

Accepted file types: jpg, gif, png, pdf, docx, doc, Max. file size: 256 MB, Max. files: 20.

If making a Third-Party Demand Package Level I referral, please include all the Medical Bills inclusive of UB04 forms, as applicable. If making a Third-Party Demand Package Level II referral, please include all Level I items plus additional documentation such as Supporting Medical Records, Police Report, Accident Investigation, Prior Medical History to assist the Nurse in their Audit & Review for Medical Necessity.

Please note, maximum number of files you can upload is 20.

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Service Referral

Service Referral

ATTENDING PHYSICIAN

ACCOUNT INFORMATION

SPECIAL INSTRUCTIONS & NOTES

To learn more about our services, please call (732)-384-3430