New Referral Form

Referrer Information

Referrer First Name

Referrer Last Name

Referrer Company

Referrer Email

Referrer Phone

Referrer Fax

I am referring from a(n):

Insurance Company or TPA

Law Firm

Other

Handling Attorney

Handling Attorney Email

Other Emails to CC (optional)

Adjuster Information

Adjuster First Name

Adjuster Last Name

Adjuster Email

Adjuster Phone

Adjuster Fax

Name of Insurance Carrier or TPA

Claimant Information

Claimant First

Claimant Last

Claimant DOB

Claimant Phone

Claimant Mailing Address

Treating Provider

Does the claimant have legal representation?

Claim Information

Claim #

Date of Injury/Loss

Benefit State

Claimed Injury(s)/Body Part(s)

Insured

Occupation

Current Work Status

Referral Information

Service Requested

Specialty Requested

Requested Provider(s) (Optional)

Report Needed by (Optional):

Additional Services:

Interpretation

Transportation

Cover Letter:

Cover Letter

I will provide my own cover letter.

Please create my cover letter for me.

File Upload

If any medical records, previous IME/MRR reports, or a cover letter are available now, you can submit them here and/or paste a file share link in the field provided. Otherwise, you can email them to support@independentmedspecialists.com once they're ready.

File upload

File Share Link (Optional)

Additional Information/Notes (Optional)