Referral Information
The person submitting the referral.
Full Name
*
First Name
Last Name
Title
*
Please Select
Adjuster
Nurse Case Manager
File Coordinator
Employee
Human Resources
Channel Partner
Other
Type of Company
*
Please Select
Insurance Carrier
Third Party Administrator
Case Management Company
Employer
Channel Partner
Other
Company Name
*
DOB *used to set up your personalized Patient Portal.
*
-
Month
-
Day
Year
Date
Your Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
How did you hear about us?
*
Please Select
I've used your services before
Contracted Partner
Conference
LinkedIn
Web Search
Sales Rep
Co-worker
Other
Please Specify
*
Billing Information
The billing address is the same as above. If no, please provide the billing information below.
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Fax Number
Please enter a valid phone number.
Billing Preference
Please Select
Snail Mail
Fax
Email
Injured Worker Information
.
Injured Worker Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Mobile
*
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Date of Injury
*
-
Month
-
Day
Year
Date
Claim #
*
Has the worker seen a dentist for the injury?
*
Yes
No
Not sure
Please provide the availability of the worker to see a dentist.
If the worker has seen a dentist, please provide the name of the dentist and location.
Injury Description
*
Please provide us with any additional information we should know and/or special handling instructions.
Please upload the FNOI and/or other documents pertaining to the claim.
Browse Files
Drag and drop files here
Choose a file
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Upon submission of this referral request, you are consenting to Workforce Dental Solutions' fees and granting them the authority to arrange the dental evaluation for the injured worker. Furthermore, you are agreeing to compensate Workforce Dental Solutions their usual and customary fee, unless there is an existing agreement for discounted pricing. Please note that the evaluation fees range from $225 to $275, the cost for x-rays varies between $150 and $500, and the charges for palliative treatment varies. Peer Reviews are $375 per hour.
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