(800) 557-8585 | (407) 677-8585 | (407) 677-7602 Fax Referrals@WorkersRehab.com

MAKING A REFERRAL

If you wish to make a referral, please fill out the form below and press submit. A case management specialist will then contact you to discuss your specific needs and obtain any additional information.

If you need our Proactive Return-to-Work Program Referral Form, please click here.

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    REFERRAL SOURCE INFORMATION

    Claim #*
    Company*
    Address*
    City*
    State*
    ZIP*
    Contact*
    Phone #*
    Ext.
    Fax #*
    Email*

     

     

    CLAIMANT INFORMATION

    Name*
    Address*
    City*
    State*
    Phone #*
    SSN
    DOB*
    DOI*
    DOR*

     

     

    DESCRIPTION OF INJURY

    Description of Injury / Body Part(s)

     

     

    PHYSICIAN INFORMATION:

    Name
    Address
    City
    State
    ZIP
    Contact
    Phone #
    Fax #

     

     

    EMPLOYER INFORMATION:

    Name*
    Address
    City
    State
    ZIP
    Phone #
    Fax #
    Contact
    Occupation
    Date of Hire
    AWW
    WCR

     

     

    ATTORNEY INFORMATION:

    Plaintiff
    Phone #
    Fax #
    Address
    City
    State
    ZIP
    Defense
    Phone #
    Fax #
    Address
    City
    State
    ZIP

     

     

    TYPE OF ASSIGNMENT:

    Medical
    Other
    Vocational
    Other
    Specialized
    Other

     

     

    SPECIAL INSTRUCTIONS / ADDITIONAL COMMENTS