What do we need for a referral?

  • First Report of Injury – if available.  If not then please send as much demographic information as possible. We at least need the DOB, SSN and a contact phone number…although we have started files without them! 

  • Signed Panel C42 with the choice of an authorized physician.  If you need a panel, then we will provide you with a recommendation.  We will follow up with the injured worker to obtain their choice and schedule the appointment as soon as possible.

  • Medical records if you have any available.  We will obtain if you do not.

  • That is absolutely all we need to get started! 

Referal Form
Upload First Report Injury
Panel C42 if Available
Medical Records if Available