Please complete our Referral Form to request our services

* Required Fields

Adjuster/Client*
Adjuster/Client E-mail*:
Company Name/Address:*:
Claimant*:
SSN*:
DOB*:
Claimant Address:*:
Date of Accident:*:
Claim Number*:

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

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 (No mental health info.) HIPAA (mental health info. Included)

Please check off the services to be performed:

Canvass Plus Service (Includes medical canvass report, medical record retrieval, HIPPA and OC-110A)
Medical Canvass Report
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)
Specialty Canvass (Orthopedic, Chiropractic, etc – 15 maximum or 20 miles radius )
Medical Record Retrieval
Background Medical Investigation (medical questionnaire)
via claimant/claimant’s counsel
Retrieve Medical records from providers**
Identify and retrieve records from additional providers

**Medical records being requested:

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