Referral Submission Form
Please complete all of the required fields and supply as much additional information as possible. After submission, an approval request will be sent to the adjuster identified in the form.
Injured Worker
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Claim Information
Claim Number
*
Date Of Injury
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Jurisdiction
*
Please Select
NH
MA
ME
VT
Injury Description
*
Accident Description
Procedure Information
Procedure Type
*
Please Select
MRI
CT Scan
Body Part
*
Side Of Body
*
Please Select
Left
Right
Not Applicable
Ordering Provider Name
*
Ordering Provider Location
*
Has a referral already been made?
Please Select
No
Yes
Provider Referral Has Been Sent To
Payer Information
Payer/Carrier
*
Adjuster Name
*
First Name
Last Name
Adjuster Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Adjuster Email
*
example@example.com
Submitter Info
Same As Adjuster
Submitted By
*
First Name
Last Name
Job Function of Submitter
Job Function of Submitter
*
Please Select
Adjuster
Provider
Case Manager
Other
Submitter Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submitter Email
example@example.com
Special Instructions
Upload Files
Browse Files
Drag and drop files here
Choose a file
Please upload any other relevant documents associated with this referral (FROI, Procedure Order, etc...)
Cancel
of
Submit
Should be Empty: