<%@LANGUAGE="VBSCRIPT" CODEPAGE="65001"%> Work Comp Doctors - Patient Referral Forms - Our Workers' Compensation medical providers are knowledgeable in the medical and legal responsibilities and reporting for the workers' compensation industry.
If this page does not present properly, you need to install or update your Flash Player Click here to download Flash Player
For Information Call: 877-266-7266
Where Responsible Providers Strive to Provide
Excellent Outcomes
If this page does not present properly, you need to install or update your Flash Player Click here to download Flash Player


home pagemembers login

  Patient Referral Instructions

 
  Please use one of the methods below to refer a patient for treatment:  
  Option 1 .
Fill out and submit on-line.
 
  Option 2 .
Print and fax the referral form.
 
  Step 3 .
We will contact you once we receive your referral.
 

Patient Referral Forms

There are two ways to refer patients to us:

1. Fill out the on-line form and submit your patient directly into our database. (Preferable)

2. Download, print out, fill in, and fax the form to us. Click here to download the fax referral form (pdf format)