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Schedule A Referral"

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Case History

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Referral Date: select / /
Adjuster: Unit#: Ext.:
Email:
Cc Name:
Cc Email:
Referral Type: Treating Specialty:
Claim Type: Specialty Requested:
Service Type: (Evaluation of Past Treatment
requires the same specialty)
Insured: *Loss/Claim#:
*Claimant: Email:
Address:
City: State: Zip:
Phone:
Attorney: Phone:
Law Firm: Fax:
Address: Email:
City: State: Zip:
Occupation:
Out of Work From: select / / To: select
Date of Injury: select Pre-Existing
Condition:
Type of Injury:
0 characters entered. | 250 characters remaining.
Description of Accident:
0 characters entered. | 250 characters remaining.
Direction of Impact: Amount of Damage
to Vehicle:$
Position Seated in Vehicle: Seat Belted?
All Exams will include the following:
Diagnosis Work History/Current Work Status
Objective Findings Prior Injuries
Causal Relationship Medical End Result
In addition to the above, please comment only on the following:
Permanency
Periods of Total/partial Disability
(only if at a medical end result)
Reasonableness of Fees.
If not, please specify
Reasonableness of treatment.
If not, what is reasonable?
Attachments?
Meds available?
Taxi?
Interpreter?
Language:
Special Requests:
Files to include:
Filename 1:
Filename 2:
Filename 3:
Filename 4:
Filename 5:
Filename 6:
Filename 7:
Filename 8:
Filename 9:
Filename 10: