Request for Bills/Records Agreement

NEW WORK COMP PATIENT REFERRAL FORM
Appointment Type
Patient Name:

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DOI

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
WC Claim Number
Injury occurred in which state (jurisdiction)?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Person Requesting Appointment

First NameLast Name
Company Name
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Email
example@example.com
Title
INJURED BODY PART
Dispensing Medications (DocRX)?
Employer Name

First NameLast Name
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Email
example@example.com
Insurance Co Name
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Network/Bill Review
Does your carrier accept electronic filing of claims?
Can you provide the EDI electronic payor ID number?
Address if different from above
Adjuster Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Ext.
Fax Number

Area CodePhone Number
Nurse Case Manager Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Ext.
Fax Number

Area CodePhone Number
Authorized By

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorization will be verified with adjuster and/or case manager. Thank you for the referral and if you have any questions please contact Angela Wright CWCP, Workers Comp Coordinator, at 770-298-8987 x118.
FOR OFFICE USE ONLY:

Appt Info

DATE:

TIME:

LOCATION:

DOCTOR:

AUTHORIZATION VERIFIED WITH:

VERIFIED BY:

DATE:
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Should be Empty:

NEW WORK COMP PATIENT REFERRAL FORM