Please complete our Referral Form to request our services

* Required Fields

Adjuster/Client*
Adjuster/Client E-mail*:
Company Name/Address*:
Additional Contacts/CC's for File:
Claimant*:
SSN*:
DOB*:
Claimant Address*:
Claimant Phone Number*:
Date of Accident*:
Claim Number*:

WCB Number:
Accepted Injury Site(s)*:
Employer Name:
Attorney:
Attorney Phone:
Attorney's Address:
Special Instructions for File:

HIPAA/OC-110A:

Are you in receipt of a signed HIPAA authorization from the claimant?

If no, please indicate which authorization you would like our office to obtain:
HIPAA

SERVICE REQUEST

Canvass Plus Service (Includes medical canvass report consisting of 15 hospitals, 15 clinics, and 10 pharmacies, HIPAA/OC-110A retrieval, and medical record retrieval)

Build Your Own Canvass Plus Service (Includes medical canvass report (up to 3 selections of your choice), HIPAA/OC-110A retrieval, and medical record retrieval)

Please select up to 3:

Hospital Canvass
Pharmacies
Clinics
Orthopedic
Chiropractic
Pain Management
Other (please specify):

Medical Canvass Report only:
Hospital Canvass (15 maximum or 20 mile radius)
Pharmacies (15 maximum or 20 mile radius)
Clinic (10 maximum or 20 mile radius)
All-inclusive canvass (including the 3 above)
Additional canvass (specified radius over 20 miles):

Medical Record Retrieval only:
Background Medical Investigation (medical questionnaire)
via claimant/claimant’s counsel
Retrieve Medical records from providers**
Identify and retrieve records from additional providers

Additional Service(s):
Additional Canvass (1 additional specialty): SPECIALTY:
Specialty Canvass (2 additional specialties): SPECIALTIES:


RECORDS BEING REQUESTED:

Prior Medicals Only
Current Medical Records Only
Injury Site(s) Only
Any and All Medical Records
Mental Health Medicals
Prior Medicals for Injury site(s) only
Other/Specific Dates:


UPLOAD FILES:

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Select File 2:
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Select File 4:
Select File 5: