Workers' Compensation Referral Intake Form

INTERPRETER NEEDED?

YesNo

Today's Date

PATIENT INFORMATION

Patient Last Name

First Name

Middle Initial

Address

Apt #

City

State

Zip

Social Security Number

Date of Birth

Home Phone

Work Phone

Cell Phone

Emergency Contact

Phone

Occupation

Date of Injury

Injury/Condition (Include specific body part)

Has patient had surgery on the injured area?

YesNo

Surgery procedure performed:

Attorney

Is an attorney involved?

YesNo

Phone

Representing:

PatientCarrierEmployer

Special Reports already available:

DOCTOR REFERRED TO

Which Vanderbilt doctor are you referring to?

Has the patient seen another doctor for this same injury/condition

YesNo

If "Yes", please list doctor's name and address:

Treating Physician

Address

City

State

Zip

Phone

Fax

COVER LETTER REQUESTED FOR ALL CONSULT/ OPINION/ IME

Type of Appointment

EMPLOYER INFORMATION

Employer

Contact

Address

City

State

Zip

Phone

Fax

e-mail address

WORKERS' COMP CARRIER INFORMATION

Claim Number

Durable Medical Equipment (DME) okayed?

YesNo

Consent Release form requested?

YesNo

Carrier

Adjustor

Address

City

State

Zip

Phone

Fax

e-mail address

Case Manager

Company

Phone

Fax

e-mail address

Is pre-certification required for additional testing or hospitalization?

YesNo

If "Yes", pre-cert Phone Number

Pre-cert Fax Number

PATIENT CAN MAKE OWN APPOINTMENTS?

YesNo

COMMENTS:

Consult/Referral given/Approved by

e-mail address:

(Required for us to submit appointment confirmation via e-mail)

THIS INFORMATION IS BEING TRANSMITTED OVER A SECURE, ENCRYPTED LINE.

This e-mail may contain confidential and privileged information for the sole use of the intended recipient(s). Any review, use, distribution, or disclosure by others is strictly prohibited.

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