REFERRAL FORM
Referring Party's 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
Date of Birth
-
Month
-
Day
Year
Date
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 Injury
*
-
Month
-
Day
Year
Date
Claim #
*
Requested Service
Please Select
Dental Evaluation + Treatment Management
Treatment Management
Dental Peer Review
Independent Medical (Dental) Evaluation
Second Opinion
Dental Surgical Clearance
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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By submitting this referral request, you consent to Workforce Dental Solutions' fees and authorize them to schedule the dental evaluation for the injured worker. You also agree to pay their standard fees for these services, unless a discounted pricing agreement is in place. Evaluation fees range from $225 to $475, x-rays cost between $150 and $500, and palliative treatment costs vary. Peer Reviews are billed at $375 per hour. Please note that if your case is settled or closed after a clinical review to determine causality or after a review of the treatment plan for necessity and injury relatedness, a final fee of $375 will be charged for a Peer Review.
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