ProMedView Referral Form

Referral Form
Please complete all applicable fields and submit with supporting medical records, medication list, diagnostic testing, and prior behavioral health records (* indicates a required field).
CLAIMANT INFORMATION
Claimant Name

Last NameFirstName
Claim Number
Date of Injury

MonthDayYear
Claim Jurisdiction (State)
Claimant Demographics
Date of Birth

MonthDayYear
Gender
Primary Language
Interpreter Needed?
Claimant Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Claimant Email
example@example.com
Claimant Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Claimant Current Location

Facility Name or Residence Type

Address

CityState / Province

Postal / Zip Code
Employment
Current Work Status
Occupation
Request
Accident Description
Injury description, hospitalization history, body parts injured, etc.
Summary of Concerns
Service Delivery
Ability to Participate in Telehealth?
Transportation Needed?
ADA Accommodation Needed?
List Required Accommodations
Claim Management Contacts
Referral Made By
Referral Source Name

First NameLast Name
Referral Source Phone
Please enter a valid phone number.Format: (000) 000-0000.
Referral Source Email
example@example.com
Referral Source Organization
Company
Claims Examiner Email
example@example.com
Claims Examiner Name

First NameLast Name
Claims Examiner Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Carrier / Payor
Treating Medical Physician Name
Treating Medical Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Treating Medical Provider Fax
Please enter a valid phone number.Format: (000) 000-0000.
CLINICAL INDICATORS
BH Needs
Confirmed BH Diagnoses
Documentation Needed
Please submit:
- Medical records
  - Hosptial Discharge
  - Rehab Discharge
  - Recent MD Appointment Notes
  - Work Release (if applicable)
- Medication list (if applicable)
- Diagnostic reports (if available)
- Imaging reports (if applicable)
- Prior behavioral health records (if applicable)
Medical Records Attached
File Upload

Cancelof
Confirm Submission
Thank you for choosing ProMedView.

Integrated behavioral health services with a focus on resilience and recovery, resulting in improved return-to-work outcomes and reduced long-term costs associated with claims.
ProMedView Strategic Clinical Solutions

7862 W. Irlo Bronson Memorial Highway, Suite 334 Kissimmee, FL 34747 Office: 407-988-4090 consult@promedview.com | Fax: 407-545-8000
BHSNV220250118
Should be Empty:

Referral Form

CLAIMANT INFORMATION

Claimant Demographics

Employment

Request

Claim Management Contacts

CLINICAL INDICATORS

Documentation Needed