Hurtado CM Referral Form

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SECURE REFERRAL PROFILE SUBMISSION FORM

Completing the fields below enables us to make timely and efficient case management assignments. Email confirmation of referral receipt will be sent same business day. Nurse are assigned within 24 hours (business day). Click on the START button to begin. When finished with all sections please click on the SUBMIT button at the end of this form to complete the submission.

1
Referral Information
Date of Referral
Claim Number
2
Case Type
Field
Field Task
Telephonic
Telephonic Task
Other
3
Is Spanish Translation Needed?
Yes
No
Other Language
4
Priority
Standard
Rush
5
Claims Information
Company Name
Examiner Name
Phone
Fax
Email
Billing Address, City State, Zip Code
6
Employee Information
Employee Full Name
Employee Date of Birth
Employee Phone
Employee Email
Employee Address, City State, Zip Code
7
Employer Information
Employer Name
Employer Contact Person
Employee Phone
Employee Email
Employer Fax
EE Occupation
Employer Address, City State, Zip Code
8
Criteria for Benchmarks
Date of Injury
Accepted Injury/Body Part
Last Day Worked
Mod Duty Release Date
T.T.D. Start Date
Avg Weekly Wage
9
Physician Information
Name
Treating M.D.
Phone
Fax
Email
Address, City State, Zip Code
10
Attorney Information
Name
Phone
Fax
Email
Address, City State, Zip Code
11
File Upload
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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12
Special Instructions
Should be Empty:

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