Request a Trust Certified Provider

Please complete the form below.

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WE SELECT TRUSTED PROVIDERS WITHIN YOUR DESIGNATED PARAMETERS , WHO ARE EXPECTED TO CREATE BEST PATIENT OUTCOMES, SATISFIED CLAIMANTS, AND COST SAVINGS

Requesting Party(Required)

Company Name(Required)

Email(Required)

Phone

Fax

Insurance Type(Required)

Workers' Compensation

Auto

Liability

Other

Claim Number(Required)

Employer Name

Date of Injury(Required)

Date of Birth(Required)

Patient's Phone #(Required)

Description of Injury/Body Parts to Evaluate(Required)

Type of Evaluation Requested(Required)

Evaluation & Treatment

IME

2nd Opinion

Records Review

Other

Other:

Specialty Requested(Required)

Other (If not listed above)

Zip code(Required)

Additional Comments/Special Handling

Request a Trust Certified Provider

Request a Trust Certified Provider NewNew

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