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Submit A Referral

Secure Electronic Records Upload

Referrals

We accept referrals in a variety of ways including hard-copy print, email, fax or secure electronic upload.

Electronic Forms

Downloadable Forms

Download Referral Form

Authorization & Consent

Online Referral Form

Secure Electronic Records Upload

Section 111
Queries and Reporting

ORM & TPOC Input

Having trouble downloading our referral form? Click here.

Documents Needed for Allocations

In order to prepare the most accurate allocation possible, we need the following documents:

Most recent two years of medical records
First report of injury in workers' compensation cases
Claims payment history/listing
Pharmacy printout
Summary of medications (if available)
Completed referral form

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