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Online Referrals

To expedite the referral process and to provide a format for timely, efficient and complete communication of information needed to meet the needs of you and your client/employee/insured, we have provided a platform for you to electronically submit completed referral forms to our firm.

After choosing the appropriate product from our continuum of services, you can now simply complete our on-line referral form and submit them directly to us, through our website. These forms can also be printed and faxed to our office if you so prefer (574-825-3355). Our administrative staff will process them immediately upon receipt and our professional staff will be in contact with you at the earliest possible time (See our service/referral guarantee for initiation of services).

We have streamlined this process to provide a seamless and simple format for conveying vital case information, enabling our staff to expedite the initiation of services, with the least amount of invested time on your part.

Telephonic referrals are also processed with the same degree of priority and efficiency. Just call 574-825-9000. No matter what modality of referral you choose, our guarantee remains the same.

 

Referring Company:
Referral Reason:	IME 2nd Opinion Life Care Plan Medical Legal/LNC Cost Projection Medicare Set-Aside Allocations Case Management/limited assignment       Telephonic  Onsite Case Management/complete assignment       Telephonic   Onsite Other
Referred By:
Contact:
Phone:
Fax:
Email:
Address:
City/State/Zip:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Case Manager/Life Care Planner/Legal Nurse Consultant:	(indicate name of special request case manager if desired)
Carrier/Firm:
Contact Name:
Title:
Phone:
Fax:
Email:
Address:
City/State/Zip:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Patient Name:
DOB:
DOI:
Claim #:
SSN:
Phone:
Alternative Phone/Cell:
Address:
City/State/Zip:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Employer Name:
Contact Name:
Phone:
Fax:
Email:
Address:
City/State/Zip:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Treating Physician:
Facility:
Phone:
Fax:
Email:
Address:
City/State/Zip:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Diagnosis:
Diagnosis Code:
Other Physicians/Facilities:
Other Info:
Special Instructions: