Case Management Referral Form

Click Here to Download

Download the Word version of our CMRF when reporting a new injured worker case.

Feel free to contact the case manager on call 24 hours a day / 7 days a week. You will be contacted directly regarding assignment of the file to our Case Management Staff.

Phone: 888-718-7074
Fax: 888-891-2368 (Fax completed form to this number.)


HIPAA Release Form

Click Here to Download
Click Here to Download – Espanol


ProActive Partners Inc. W9

Click Here to Download