Case Management Referral Form Fields with an asterisk(*) are required. Requested By TPA/Insurance Co.*: Adjuster Name*: Phone*: Email*: Phone (Direct): Fax: Additional Information Case Type: —Please choose an option—TCMFCMTaskCAT Classification*: NonsubscriberWork Comp State Jurisdiction: —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaIdahoIllinoisIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsin Special Instructions: Employer Information Name*: Contact Name*: Address 1: Address 2: City: State: —Please choose an option—AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip: Phone: Fax: Email: Employee Information Name*: Phone*: Date of Birth*: Body Part*: Email: Claim Number: Address 1: Address 2: City: State: —Please choose an option—AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip: Occupation: SSN: Date of Hire: Date of Injury: Accident Description: Diagnosis: Physician Name: Phone: Address 1: Address 2: City: State: —Please choose an option—AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip: Fax: Attachment Please attach the First Report of Injury (if available). This will help us process your case more efficiently. Must be PDF and max file size is 2MB. Or you may fax the First Report of Injury directly to our Referral Fax # 888.225.9087 Attach Report: Verify Submission - You MUST check the box below A friendly reminder to verify all the fields, to enable us to address the case quickly. I have verified all the fields.