Online Referral Form
Referrer Information
First Name:
Last Name:
Company Name:
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Texas
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Washington
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Wisconsin
Wyoming
Phone:
XXX-XXX-XXXX
Email:
Service Requested
Services Available
Services Selected
Investigative Services:
Surveillance
Social Media Research
Activity Check
Alive and Well Check
-----
Record Retrieval Services
Activity Check (in-person)
Activity Check (virtual or telephone)
Address Check
AOE/COE
Asset Check
Background Check Accident records
Background Check Addresses (10-years)
Background Check Bankruptcy filings
Background Check Business ownership
Background Check County civil & criminal (10-years)
Background Check Judgment & liens
Background Check Prior Claims
Background Check Professional licenses
Background Check Property records
Background Check Vehicle registrations
Background Checks
Canvass
Chiropractic Check
Clinic Inspection
Criminal/Background Check
DMV-Vehicle Search
Document/Records Retrieval (desktop)
Document/Records Retrieval (field)
Documents
Driving History
Extra Copies of CD/VHS/Report
Extra Copies Social Media
Face-to-Face
Field Investigation
Fraud Investigation
Georgia Lien Search
Hospital Check
Interviews & Recorded Statements (in-person)
Interviews & Recorded Statements (virtual or telephone)
Investigation
Legal Attendance or Trial Monitoring
Live Testimony
Locate
Locus Photos with Statement
Locus Photos without Statement
Medical Records Canvass
MRI Check
Neighborhood Canvass
Official Document Retrieval
Orthopedic Check
Other-IS
Pharmacy Check
Phone Statement
Photos
Record/Interview
Recorded Statement
Research
Scene Investigation
Skip Trace
Sports and Leisure Check
Texas Lien Search
Trial Preparation
Urgent Care Canvass
Widow Check
Witness Statements
Written Statement
Medical Management:
IME
Medical Record Review
-----
ACT 6 PA PRO
Addendum
AIS FCE
AIS IME/Record Retrieval
CME
Conditional Payment Update
Controverting Affidavit
CPT Code-Medical Review
DBA
DDE-TX
Disability IME
FCE
Fee Negotiation
Film Review
Hospital Audit
IME Re-exam
IME-NOFAULT/PIP
IME/AD&D Appeals
IME/AD&D Core
IME/Appeals
IME/CORE
Intra-Operative Photo Review
Peer Review
Peer Review/AD&D Appeals
Peer Review/AD&D Core
Peer Review/Appeals
Peer Review/Core
Peer Review/Fee Audit
Post DDRME-TX
Rebuttal
RME-TX
Scheduled Loss of Use
SOCRATES
Stand Alone Waiver
Surgical Peer
Surgical Peer/ Fee Audit
Video Deposition
Special Case Instructions:
Claimant Information
New Claimant
Existing Claimant
First Name:
Last Name:
Address1:
Address2:
City:
State:
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Email:
Phone:
XXX-XXX-XXXX
Cell:
XXX-XXX-XXXX
Date of Birth:
MM/DD/YYYY
Gender:
-Select-
Male
Female
Marital Status:
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Married
Single
Divorced
Social Security Number:
Special Physical
Characteristics:
For example:
glasses, tattoos, facial hair, hand dominance
Claim Information
Type of Case:
-Select-
A&H
APD - PL SIU DG
Auto Bodily Injury
Auto Bodily Injury - PL
Bodily Injury- PL SIU DG
DBA
Family Medical Leave Act (FMLA)
Florida NF/PIP
General Liability
GH
Homeowners
Long Shore
Long Term Care
Long Term Disability
Mass PIP
Med Pay
Michigan PIP
New Jersey Auto
New York NF/PIP
NF/MP - PL SIU DG
Pension Fund
PIP/No Fault
Private Sector (Self Insured)
Property
Property - PL SIU DG
Short Term Disability
Subrogation
USL&H
Workers Compensation
Claim Number:
Insured
Date of Loss:
MM/DD/YYYY
Jurisdiction
-Select-
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Physical Problems
Please Select
Problems
as Appropriate:
Abdominal
Amputation
Anxiety
Arthritis
Asthma
Back
Balance issues
Bilateral Knee Pain
Bilateral Legs
Bilateral Shoulder Pain
Bipolar
Bladder
Brain Injury
Bruise/contusion
Burns
Buttock
buttocks
Cancer
Cardiac
Central Nervous System
Chemical Exposure
Chest
Chest Pains
Chin
Chronic Fatigue Syndrime
Cognitive Issues
Collarbone
Concussion
COPD
CRPS
CTS
Cumulative Injury
Deceased
Depression
Diabetes
Difficulty ambulating
Dizziness
Ears
Eating disorder/anorexia or bulimia
Electrocution
Erectile Dysfunction
Eyes
Facial Lacerations
Facial Nerve Injury
Fatality
Fatigue
Fingers
Forehead
GERD
Groin
Head
Headaches
Hearing Loss
Heart Attack
Hernia
Hypertension
Hypotension
INDEMNITY
Infectious Disease/Bodily Fluid Exposure
Ingestion of foreign body
Insomnia
Insomnia/difficulty sleeping
Internal injuries
Jaw
Left Ankle
Left Arm
Left Big Toe
Left Brachial Plexus
Left Ear
Left Elbow
Left Eye
Left Foot
Left Hand
Left Heel
Left Hip
Left Knee
Left Leg
Left Lower Extremity
Left Middle Finger
Left Pinky Finger
Left pointer finger
Left Ring Finger
Left Shin
Left Shoulder
Left Side
Left Side/Ribs
Left Thigh
Left Thumb
Left Upper Extremity
Left Wrist
Lips
Loss of Bladder Control
Loss of Concentration
Loss of consciousness
Loss of Consortium
Low Back
Lungs
Lupus
Memory Impairment
Memory Loss
Mouth
Nausea/Vomiting
Neck
Neck/Back
No injury
Nose
Not Specified
Osteopenia/Bone Loss
Pain
Paraplegia
Patellar Tendinitis
Pelvis
Post Traumatic Stress Disorder
Prescription Drug Dependency
Psychological
Pulmonary
Quadraplegia
Rash/Dermatitis
Ribs
Right Ankle
Right Arm
Right Bicep
Right Big Toe
Right Brachial Plexus
Right Clavicle
Right Ear
Right Elbow
Right Eye
Right Foot
Right Hand
Right Heel
Right Hip
Right Knee
Right Leg
Right Lower Extremity
Right middle finger
Right Pinky Finger
Right pointer finger
Right ring finger
Right Shin
Right Shoulder
Right Side
Right Side/Ribs
Right Thigh
Right Thumb
Right Upper Extremity
Right Wrist
RSD
Sadness
Scarring
Scrotum
Seizures
Sepsis/SIRS
Sinuses
Sleep Apnea
STOMACH STRAIN
Stress
Stroke
Tailbone
Teeth
Throat
Tinnitus
TMJ/Lockjaw
Toes
Tumors
Unknown-TBD
Vertebrae
Vertigo
Vision impairment
Visual changes
Visual difficulty
Visual disturbances
Whiplash
WRIST
Surveillance/Activity Check
Surveillance Amount:
-Select Hours-
40
32
24
16
8
(hours)
Other Amount:
Surveillance
Instructions/Objectives:
Upcoming Appointment:
Yes
No
Type:
-Select Type-
Physician
IME
Other
Appointment Date:
MM/DD/YYYY
Time:
-Hour-
1
2
3
4
5
6
7
8
9
10
11
12
-Minute-
00
05
10
15
20
25
30
35
40
45
50
55
-AM/PM-
AM
PM
Physician Name:
Address
City
State
-Select-
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
ON
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code
Transportation Provided:
Yes
No
Investigative Service Instructions
Receive Report via Email:
Yes
No
Rush Referral:
Yes
No
Report Needed By:
MM/DD/YYYY
Soft tissue claim:
Yes
No
Referral sent to SIU Dept:
Yes
No
Fraud Management
Special Instructions:
Medical Service Instructions
Date Exam Needed By:
MM/DD/YYYY
Next Day Report:
Yes
No
Re-evaluation:
Yes
No
Litigated:
Yes
No
Board Directed:
Yes
No
NY Board Number
NY District Office
Requested Specialty:
Acupuncture
Acupuncture/Chiropractor
Addiction Medicine
Addiction Psychiatry
Aerospace Medicine
Allergist & ENT
Allergy
Allergy And Immunology
Anatomic Pathology
Anesthesiology
Audiology
Blood Banking/Transfusion Medicine
Brain Injury Medicine
Cardiac Electrophys
Cardiology
Cardiovascular
Child & Adolescent Psychiatry
Chiropractor
Clinical Cardiac Electrophysiology
Clinical Genetics
Clinical Neurophysiology
Clinical Pathology
CRC
Critical Care Medicine
Critical Care Medicine/Surgery
Dentistry
Dermatology
Diabetes And Metabolism
Diagnostic Radiology
Emergency Medicine
Endocrinology
Epilepsy Specialist
Family Practice
Female Pelvic Med and Recon Surgery
Foot and Ankle
Forensic Cardiology
FORENSIC MEDICINE
Forensic Pathologist
Forensic Psychiatry
Functional Capacity
Functional Capacity Evaluation
Gastroenterology
General Surgery
General Surgery; Vascular Surgery
General Vascular Surgery
Geriatric Medicine
Geriatric Psychiatry
Hand Surgery
Hand, Shoulder & Elbow
Hand, Shoulder & Elbow
Hematology
Hermatology
Hospital Medicine
Immunology
Infectious Disease
Internal Medicine
Interventional Cardiology
Interventional Radiology
Licensed Social Worker
Massage Therapy
Maternal-Fetal Medicine
MBR Specialist
Medical Bill Review
Medical Oncology
Multiple Specialties (WEB)
Naturopathy
Nephrology
Neuro Ophthalmology
Neurology
Neuromuscular Medicine
Neuropsychiatry
Neuropsychology
Neuroradiology
Neurosurgery
Neurotology
Nuclear Medicine
Nuclear Radiology
Nurse
Nurse;HBA
Obstetrics & Gynecology
Occupational & Environmental Medicine
Occupational Medicine
Occupational Therapy
OMT (Osteopathic Manipulation Treatment)
Oncology
Ophthalmology
Ophthalmology (Retina Specialist)
Optometry
Oral & Maxillofacial Surgery
Oral Surgery
Orthodontics
Orthopedic Surgery
Orthopedic Surgery (Shoulder)
Orthopedic Surgery(Hip & Knee)
Orthopedic/Acupuncture
Orthopedic/Acupuncture
Orthopedics
Osteopath
Other
Otolaryngology
Otolaryngology - Head and Neck Surgery
Pain Management
Pain Management/Anes
Pathology
Pathology
Pediatric Emergency Medicine
Pediatric Neurology
Pediatric Orthopedic Surgeon
Pediatric Pulmonary
Pediatrics
Peridontics
Periodontics
Pharmacology
Physical Medicine & Rehabilitation
Physical Medicine and Rehabilitation/Acu
Physical Therapy
Physician Assistant
Physiotherapy
Pinnacle
Plastic Surgery
PM/Acupuncture
PMR/Acupuncture
PMR/Anesthesiology
PMR/Pain Management
Podiatry
Prosthetics
Psychiatry
Psychology
Psychosomatic Medicine
Psychosomtic Medicine
Public Health & General Preventative Medicine
Pulmonary Medicine
Radiation Oncology
Radiology
Rheumatology
Sleep Medicine
Speech Pathology
Spine Specialist
Sports Medicine
Surgical Critical Care
Thoracic Surgery
Toxicology
Undersea & Hyperbaric Medicine
Urogynecology
Urology
Vascular And Interventional Radiology
Vascular Neurology
Vascular Surgery
Veterinary Medicine
Vocational Case Management
Special Services
Taxi Service:
Yes
No
Interpreter Service:
Yes
No
Language:
English
French
Italian
German
Portuguese
Spanish
---------
Arabic
Czech
Chinese (s)
Chinese (t)
Danish
Greek
Hebrew
Hindi
Hungarian
Persian
Japanese
Korean
Dutch
Norwegian
Polish
Romanian
Russian
Swedish
Turkish
Thai
Ukrainian
Urdu
Certified Mail:
Yes
No
Medical Management
Special Instructions:
Claims Questions for Examining Physician
I will be submitting my own cover letter for this referral
History, Diagnosis, Prognosis
Treatment Reasonable & Necessary
Present Work Status
Physical Capacity Form/FCE
Work Restrictions (Duration of Restrictions)/ Light or Full Duty
Length of Disability
Causal Relationship
Degree of Disability
Permanent and Stationary Status (California)
Apportionment
M&S Statement
Pre-Existing Conditions
Radiologist to Read
End Result
Has the examinee reached MMI? (Requires physicals affidavit of recovery)
Maximum Medical Improvement
Permanent Scarring
AMA Impairment Rating
Edition 3
4
5
6
Scheduled Loss of Use
Need For Treatment
Permanency (New York Worker’s Comp)
Need For Surgery
Transportation
Attendant Care
Essential Services
Durable Medical Equipment
Prescriptions
Additional Information
Plaintiff Attorney
Defense Attorney
Employer
Treating Physician
Vehicle
Part of Subrogation?
Plaintiff Attorney
Prefix
-Select-
Dr.
Mr.
Mrs.
Ms.
First Name:
Last Name:
Firm:
Address1:
Address2:
City:
State:
-Select-
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Phone/Extension:
XXX-XXX-XXXX
Fax:
XXX-XXX-XXXX
Email:
Defense Attorney
Prefix
-Select-
Dr.
Mr.
Mrs.
Ms.
First Name:
Last Name:
Firm:
Address1:
Address2:
City:
State:
-Select-
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Phone/Extension:
XXX-XXX-XXXX
Fax:
XXX-XXX-XXXX
Email:
Employer
Employer:
Contact First Name:
Contact Last Name:
Address1:
Address2:
City:
State:
-Select-
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Phone/Extension:
XXX-XXX-XXXX
Fax:
XXX-XXX-XXXX
Email:
Treating Physician
First Name:
Last Name:
Address1:
Address2:
City:
State:
-Select-
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Phone/Extension:
XXX-XXX-XXXX
Fax:
XXX-XXX-XXXX
Email:
Vehicle
Year:
Color:
Make:
Model:
Plate #:
State:
-Select-
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming