Referral Process

Referrals can be made by calling or emailing our office, faxing, mailing or contacting the preferred consultant directly.

Once a Referral is received by our office, the consultant will be notified immediately.

Initial reports are written within two weeks of the initial contact with the claimant, then progress reports are written every thirty days.

We offer Flexibility with our accounts. Special handling requests will be accommodated.

Consultants are available to review the files prior to referral if requested.

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Patient Referral Form


Patient Information:

Patient Name 

 Patient Mailing Address

 Patient City, State and Zip 

Patient Phone                       Date of Birth (Patient)    

 Social Security Number   

 Date of Injury               

Patient Email

Employment Information:

Employer Name       Employer Contact

Employer Mailing Address

Employer City, State and Zip 

Employee Job Title         

Employer Phone                    

Employer Fax                           
Employer Email









Billing Information:

Referred By         Organization    

Billing Mailing Address

Billing City, State and Zip 

Claim Number              

Billing Phone                    

Billing Fax                            
Billing  Email



Primary Insurer

Secondary Insurer


Service Required:

Medical Case Management

Vocational Case Management

Medical Cost Estimate

Reserve Setting





Attorney Information:



Attorney Mailing Address

Attorney City, State and Zip 

Attorney Phone                    

Attorney Fax                           
Attorney  Email


Type of Claim:

No Fault Automobile

Workmans Compensation

Long Term Disability




Reporting and Invoicing:

Reports mailed to Referring Office

Invoices Mailed to Referring Office

Both Reports and Invoices Mailed to Referring Office




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