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
Adjuster

Claimant

Name *

First

Last

Claim Number *

State File 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

Plaintiff 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.

Drag & Drop Files, Choose Files to Upload

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

If applicable

Comments

Email *