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

MAKING A PROACTIVE RETURN TO WORK REFERRAL

If you wish to request MSA services, 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*
    Adjuster*
    Phone #*
    Ext.
    Fax #*
    Email*

     

     

    CLAIMANT INFORMATION

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

     

     

    DESCRIPTION OF INJURY
    Description of Injury*

     

     

    PHYSICIAN INFORMATION:

    Name*
    Address*
    City*
    State*
    ZIP*
    Phone #*
    Fax #*

     

     

    EMPLOYER INFORMATION:

    Name*
    Address*
    City*
    State*
    ZIP*
    Contact*
    Phone #*
    Fax #*

     

     

    SPECIAL INSTRUCTIONS / ADDITIONAL COMMENTS