Referral Form

Date:

REFERRAL SOURCE


*First Name


*Last Name


*Phone #

Ext.

*Fax #


*Email




*Company




*Address


*City


*Province


*Postal Code

PRIMARY SOURCE (if applicable)


Name


Company


Address


City


Province


Postal Code

POLICY INFORMATION

Claim # Policy #
Policy Holder Name (If different from Claimant Name)
First Name Last Name

CLAIMANT INFORMATION


*First Name


*Last Name


Address


City


Province


Postal Code


Date of Birth
(mm/dd/yyyy)

/ /

Date of Disability
(mm/dd/yyyy)

/ /

Primary Phone #


Gender

Male Female

Alternate Contact


Phone #


Lawyer Name


Phone #


Address


City


Province


Postal Code


Physician Name


Phone #


Address


City


Province


Postal Code


Employer Name


Phone #


Address


City


Province


Postal Code

MEDICAL INFORMATION


Nature of Disability

Cardiac Musculoskeletal Neurological Psychiatric
Other

Diagnosis:

ANCILLARY SERVICES


Interpreter Required

Yes No

Transportation Required

Yes No

Language


Other

SERVICE(S) REQUESTED

1 Pt Assessment
2 Pt Assessment
3 Pt Assessment
Addendum
Ergonomic Assessment
Exercise Program
FAE
2 Day FAE
Field Visit
JSTP
MSE
Labour Market Survey
PDA
POET
Return to Work Program
Situational Assessment - 1 Day
Situational Assessment - 2 Day
Situational Assessment - 3 Day
TSA
Vocational Testing
Worksite Assessment
Vocational Assessment (please specify)
     TSA Labour Market Survey Vocational Testing   

IME     Type   

Assessment Confirmation to be sent by Email Fax
Claimant Confirmation Letter required Yes No     Timeframe  
Comments / Special Instructions
File 1: + Add

File 2: + Add
File 3: + Add
File 4: + Add
File 5: + Add
File 6: + Add
File 7: + Add
File 8: + Add
File 9: + Add
File 10: