Service Referral Form

Referral Type*

Nurse Case Management
Third Party Demand Package Review - Level I - Medical Bill Repricing
Third Party Demand Package Review - Level I & II - Medical Bill Repricing & Nurse Medical Necessity Audit & Review
First Party Medical Bill Review Audit Service
Vocational Rehabilitation
Other

Other (please specify)

Referral Date:*

Referred By*

TYPE OF CLAIM – PLEASE CHECK ONE*

Workers' Compensation
Liability
Auto No Fault

Claimant/Injured Worker Last Name*

Claimant/Injured Worker First Name*

M.I.

M
F

Claimant/Injured Worker's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

SSN:

Employer:

Employee ID:

Claim Number:*

Date of Birth:*

Date of Injury:*

Occupation:

ATTENDING PHYSICIAN

Attending Physician:

Physician Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

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: 100 MB.

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.

CAPTCHA

Service Referral