VRS Referral

Referred By

Name *

First

Last

E-mail Address *

Insurance Carrier

Adjuster's Name *

First

Last

Insurance Carrier

Insurance Carrier's Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Carrier's Phone

Insurance Carrier's Fax

Treating Physician

Physician Name

Physician Address

Address Line 1

Address Line 2

City

State

Zip Code

Physician Phone

Employer

Employer Name *

Contact Name *

First

Last

Employer Address *

Address Line 1

Address Line 2

City

State

Zip Code

Employer Phone *

Service Requested

Services *

Initial Contact

Injured Employee
Employer
Treating Physician

Claimant

Name *

First

Last

Claim Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Type of Injury

Social Security Number

Date of Birth

Date of Injury

Date of Hire

Occupation/Job Title

Average Weekly Wage

Temporary Total Rate

Benefit State

Plaintiff's Attorney

If applicable

Attorney Name

First

Last

Firm Name

Firm Address

Address Line 1

Address Line 2

City

State

Zip Code

Attorney Phone

Attorney Fax

Defense Attorney

If applicable

Defense Attorney Name

Defense Firm Address

Address Line 1

Address Line 2

City

State

Zip Code

Defense Firm Phone

Defense Firm Fax

Defense Email

If you would like to send us patient medicals, please attach the document to the referral.

Click or drag a file to this area to upload.

Thank you for your referral. Someone on the VRS Team will be in touch soon to confirm receipt.

If applicable

Comments

Email *