Referral Form-AMC

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: