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Request for Service & Referral
(* Denotes Required Fields)
*Company Name
Address
City/State/Zip
Claim Number
*Phone
Watts
*Assigned By
Fax
Type of Coverage
*Employee Name
*Date of Injury
Occupation
Alternative Phone
Date of Birth
*SS Number
*Employer Name
*Contact Person
*Employer Contact Phone
Date of Hire
Average Weekly Wage
Comp Rate
*Plaintiff Attorney (If none, use NA)
*Phone (NA if none)
Defense Attorney
Phone
*Primary Physician
*Type of Injury
Type of Services Requested:
Attendant Care Assessment
Catastrophic Management
Medical Management
Three Point Contact
Job Development/Placement
Labor Market Survey
Re-employment Assessment
Transferable Skills Analysis
Vocational Assessment
Life Care Plan
Social Security Disability
Psychological Evaluation
Instructions & Information:
Medical Records: Enclosed Will Send
Job Description: Enclosed Will Send
Rehabilitation Advisors 4545 Edgewater DriveOrlando, Florida 32804Toll Free (800) 432-0704 Florida (407) 294-2082 Fax (407) 294-7220email: rehabadvisors@bellsouth.net
