Referral Request Form

Referral Request Form
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Member Details
First Name*
Last Name*
Middle Name
Address*
Email*
example@example.com
Member Phone Number*
Please enter a valid phone number.
City*
State*
Zip Code*
County*
Firm Details
Benefit Coverage Requested*
Deadline or Court Date

MonthDayYear
Is there a current deadline or court date?
Conflict?*

YesNo
Opposing Party*
City or County Where Incident Occurred*
Brief Description of Legal Issue*

0/3000
Suggest RAD Attorney Option 1*
Suggest RAD Attorney Option 2
Intake Information
Intake No.*
Membership No.*
Maximum of 10 character/s only
Is This a 2024 Plan?*

YesNo
Provider Contact Details
Provider Full Name*
Provider Email Address*
Provider Contact No.*
Please enter a valid phone number.
Did attorney provide B1 consultation prior to making referral?*

YesNo
Did you provide supporting documents to make a referral?*

YesNo
Supporting Documents

Cancelof
Cancelof
Should be Empty:

If you need to contact us regarding an existing matter, click here