Integral Consulting Services, Inc. – Integral Consulting Services Referral Form

Integral Consulting Services Referral Form

Please complete the form below with as much information as you have. If you have any questions, need any help, or would like to send us files instead of using the file upload section provided at the end of this form, please email us or call us:

Phone: 631.264.1300
Email: info@integralsvcs.com

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Integral Consulting

Form Number
Date
MM slash DD slash YYYY
Claim Number
Type of Referral
Type of Claim
Jurisdiction
Contact Email for Referral
Date of Injury
MM slash DD slash YYYY
Insured
Date Report Needed By
MM slash DD slash YYYY
Company Information
Company
Representative
Address 1
Address 2
City / State / Zip
Phone
Fax
Claimant Information
Claimant
Claimant's Date of Birth
MM slash DD slash YYYY
Last 4 Digits of Claimant SSN
XXX-XX-
Address 1
Address 2
City
State
Zip Code
Phone
Fax
Legal Information (Defense Liability Case)
County Venued
Defense Firm
Attorney
Address 1
Address 2
City / State / Zip
Phone
Fax
Legal Information (Plaintiff)
Plaintiff Firm
Attorney
Address 1
Address 2
City / State / Zip
Phone
Fax
Workers Compensation Information
ANCR
WCB Number
Sites of Injury
Treating Doctor
Phone
Address
City
State
Zip Code
Treating Doctor 2 (when applicable)
Phone
Address
City
State
Zip
Treating Doctor 3 (when applicable)
Phone
Address
City
State
Zip Code
Treating Doctor 4 (when applicable)
Phone
Address
City
State
Zip Code
Treating Doctor 5 (when applicable)
Phone
Address
City
State
Zip Code
Ancillary Services
Interpreter
If an interpreter is needed for this exam, please indicate the language needed.
Is transportation needed for the claimant?
- Yes
- No
Medical Information
Previous Examiner and Exam Date (for Re-Exam)
Does the carrier have films? (for Radiology Review)
- Yes
- No
- Need to Obtain Films (please fas authorization)
Specialty Required (click those that apply)
- Acupuncturist
- Anesthesiologist
- Cardiologist
- Chiropractor
- Chiropractor/Acupuncturist
- Chiropractor/MUA
- Dentist
- Dermatologist
- Family Practitioner
- Gastroenterologist
- General Surgeon
- Geriatric Medicine
- Hand Surgeon
- Infectious Disease
- Internist
- Neurologist
- Neuro-Ophthalmologist
- Neuro-Psychiatrist
- Neuro-Psychologist
- Neuro-Radiologist
- Neurosurgeon
- Obstetrics and Gynecology
- Occupational Medicine
- Ophthalmologist
- Oral Surgeon
- Orthopedic Spinal Specialist
- Orthopedic Surgeon
- Osteopath
- Otolaryngologist (ENT)
- Pain Management
- Pain Management/PMR
- Pain Medicine
- Pain Medicine/PMR
- Pathologist
- Physiatrist (PMR)
- Physiatrist/Acupuncturist
- Physical Therapist
- Plastic Surgeon
- Plastic Surgeon (Facial)
- Podiatrist
- Psychiatrist
- Psychologist
- Pulmonologist
- Radiologist
- Reconstructive Hand Surgeon
- Rheumatologist
- Thoracic Surgeon
- Trauma Surgeon
- Urologist
- Vascular Surgeon
Other Specialties
Do you require a specialty not listed above? Please note it here.
Issues to Be Addressed (click those that apply)
- Anticipated Return to Work
- Causal Relationship
- Degree of Disability
- Work Restrictions
- Maximum Medical Improvement
- Need for Treatment
- Frequency/Duration of Treatment
- Need for Testing
- Schedule Loss of Use
- Permanency
- Prognosis
Additional Issues to Address
File Upload & Submit
Max File Size: 100 MB | File Types Allowed: pdf, doc, wps, jpg
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Integral Consulting Services Referral Form

Integral Consulting

Company Information

Claimant Information

Legal Information (Defense Liability Case)

Legal Information (Plaintiff)

Workers Compensation Information

Ancillary Services

Medical Information

File Upload & Submit