(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