TYPE OF REFERRAL REQUESTED:

ADDITIONAL SERVICES
Medical Cost ProjectionsLife Care Plan ReviewLegal Nurse ReviewOTHER

COMMENTS (optional)

To officially submit referral, please make sure you downloaded the CMS referral form. Once you submit the above request, you will be redirected so you can securely upload additional documentation to include completed CMS Referral Form, First Report of Injury, medical records, or any other information. Please check this box to confirm that you have read this message.