Referral Form

SECURE REFERRAL PROFILE SUBMISSION FORM

Completing fields below enables us to make timely and efficient case management assignments.

Press SUBMIT button at end of this form to complete the submission.

Email confirmation of referral receipt will be sent same business day if received by 3:30 PM.
Nurse assigned within 24 hours (business day).

Date of Referral:

Leave this empty:

Claim #:
 
Claims Information:
Company: Examiner Name:
Billing Address: Phone:
City, State, Zip: Fax:
Risk Pooling Agency: Email:
 
Employee Information:
Employee Name: DOB:
Address: City, State, ZIP:
Phone: SSN#:
Accepted Injury/Body Part: DOI:
 
Employer Information:
Employer: EE Occupation:
Employer Address: City, State, ZIP:
Phone: Fax:
Contact Person: Email:
 
Physician Information:
Treating M.D.: Phone:
Address: Fax:
City, State, ZIP:    
 
Attorney Information:
Applicant's Attorney: Phone:
Address: Fax:
City, State, ZIP:    
 
Criteria for Benchmarks:
Last Day Worked: T.T.D. Start Date:
Mod Duty Release Date: Avg Weekly Wage:
 
Case Type:
Field
ⓘ Field: Cases outside of disability guidelines; COVID19; future medical, complex medical and surgery, hospital discharge; secondary treators
   Field Task
ⓘ Field task: Specific task to meet with MD: (P&S/PR4s; work status, specialty referral coordination)
   Telephonic
ⓘ Telephonic: Medical coordination of care with no attendance at visits; out-of-state files
   Telephonic Task
ⓘ Telephonic Task: Short-term specific task; out-of-state files; P&S/PR4s; work status, specialty referral
  
Ortho/Surgical Trak
ⓘ Ortho/Surgical Trak: Surgery with pre- and post-op nursing assistance; file closure at post-op visit if no complications
   Catastrophic*
ⓘ Catastrophic: Life or limb threatening injuries requiring immediate nursing services
   IMPACT EIP
ⓘ IMPACT IEP
 
Priority:
Standard    Rush   
 
*For immediate assistance, CAT or Urgent, call 925-516-3901 x100
Certified Interpreting Team:
Spanish
Other:
*Certified or provisionally certified interpreter
 
Special Instructions:

Please make sure you press the SUBMIT button at the end of this form before exiting to complete your submission.