(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.

* notes required fields

 


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