CASE MANAGEMENT REFERRAL

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Preparer's Information

Type of Claim:

<Report OnlyTelephonic Case MgmtField Case Mgmt

General Information

Employer Information

Are your Workers Compensation panels posted?

YesNo

Are your Notification Forms signed? (For PA)

YesNo

Employee Information

MaleFemale
SingleMarriedDivorcedWidowed

Full TimePart TimeVolunteerSeasonalOther
YesNo
YesNo

YesNo
YesNo

Accident Information

YesNo
YesNo

YesNo
YesNo
YesNo
YesNo
YesNo

Witness Information

Medical Provider Information

YesNo
Zip Code
YesNo
YesNo

Agent Information

Comments