Referrals

Please complete as much information below as possible. When you are finished, click the submit button at the bottom of the form.

Our form is temporarily out of service. Please PRINT THE FORM and fax it to us at: 509-536-7713 .We apologize for the inconvenience.

Injured Worker Information			Referring Agency
Injured Worker name:			Referral Date:
Claim Number:			Claims Consultant:
Phone:			Phone:
Address:			Email Address:
City, State, Zip:			Refer to:
DOB:			Services Requested:
Employer Information			Injury Information
Employer:			Accepted Condition:
Contact Person:			Date of Injury:
Phone:			Occupation:
			Wage:
Attorney Information			Physician Information
Attorney Name:			Attending Physician:
Phone:			Phone:
Comments: