Claims Representative* Claims Rep Email*@
Address Insurance Company
City Phone/Ext.
State Zip Code @A copy of the referral will be sent to this email address
Name* Phone *
Address* Date of Birth*
City* State* Zip Code*
CLAIMANT'S ATTORNEY INFORMATION (receives copy of appointment letter)
Law Firm Attorney Name
Address Phone
City State Zip Code
Fax Number    
Work Comp        Auto Liab        Auto PIP       Gen Liab       Other
Your Claim #* Date of Injury/Loss*
Insured* Description of Injury
Examination       Record Review Only       Requested Physician
Specialty:   Service Request:  
Chiropractic Appointment letter forwarded to claimant by Certified Mail
Function Capacity Exam Appointment letter forwarded to claimant by Overnight Mail
Hand Specialist Interpreter
Internal Medicine Photo Identification
Neurological Transportation
Orthopedic Bill Review
Other Other
Next Day Fax      
Verbal Notification      
Enclosed          Will Send           None 
During the evaluation, please address the following issues:
1.          What is the present DIAGNOSIS and PROGNOSIS?
2.          Is the alleged condition CAUSALLY RELATED to the accident described?
3.          Is he/she able to RETURN TO FULL DUTY WORK? If not, please include any necessary restrictions.
4.          Please comment on the DEGREE OF DISABILITY. How long was the TOTAL DISABILITY period?
                   How long was the PARTIAL DISABILITY period?
5.          Please comment on the TREATMENT RECEIVED or presently receiving.
6.          Please comment on FURTHER TREATMENT.
7.          Has he/she reached a MEDICAL END RESULT?
8.          Is there any expected PERMANENT IMPAIRMENT?
9.          Is there any SCARRING?
10.        Other, place comments below:
Attachment 1* *Please use these fields if you have medical records or pertinent documents to attach to the referral form.
Attachment 2*
Attachment 3*
Attachment 4*
Attachment 5*