(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.

* notes required fields

 


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