Upcoming Events

 

Referral Form-Disability Consults

For Immediate Scheduling Please call
800-231-5200
scheduling@consultingphysicians.com
Metro Detroit ● Flint
Central ● Western● Northern Michigan
Fax 248-357-4272 or 248-357-2380

Your Name:
Phone:
Fax:
Email Address:
Company Name/Address:
Doctor or Specialty Requested:
Location:
Claimant Name:
Phone #:
Address:
S.S. #:
Date of Birth:
Injury Date:
Claim #:
Employer:

 

Type of Evaluation:

 
Work Comp:
Pending
Open
Litigated
S&A
AUTO/PIP:
Open
PIP Litigated
3rd Party Litigated
LIABILITY:
Disability Retirement:
Fitness for Duty:
Specific Allegations/Special Instructions:
Verbal:
Yes
No
Cite:
Yes
No
Letter to Doctor:
Yes
No
Medical records Available:
Yes
No
CC:
Cite
Report
Cite and Report
To:
CC:
Cite
Report
Cite and Report
To:
PLEASE ADDRESS THE FOLLOWING:
Current Diagnosis – Prognosis
Causality
Ability to Return to Work
Restrictions (if so duration)
MMI
Current Treatment Plan
Further Treatment Necessary (if so duration)
Has the claimant reached pre-accident medical status
Replacement / Household Services
Attendant Care

 

APPOINTMENT CONFIRMATION

 
Your Appointment has been scheduled with Dr.:
Date:
Time:
Location:

 

 
 

 
 
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