Claims Examiners' Case Management Request Form:
For questions or to make referrals via email/phone, please contact us at
info@rehabwest.com
or
(760) 759-7500
Use the Tab key to navigate through the form:
Please enter all dates like:
mm/dd/yyyy
Items in
Red
must be entered.
PDF Form
Injured Employee:
First Name:
MI
Last
Address:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
DC
WV
WI
WY
--
AB
BC
MB
NB
NF
NT
NS
ON
PI
PQ
SK
YT
GU
OU
PR
Zip:
Phone:
Primary Language:
Occupation:
Department:
Date of Hire:
Birth date:
SSN:
Injury date:
If injury date is not relevant, enter: 01/01/1900
Gender:
M
F
LDW
TD Rate:
Employer:
Company:
Address:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
DC
WV
WI
WY
--
AB
BC
MB
NB
NF
NT
NS
ON
PI
PQ
SK
YT
GU
OU
PR
Zip:
Phone:
Fax:
Email:
Contact:
Modified Work Available?
Y
N
Defense Attorney:
Same as last referral
First Name:
Last Name:
Firm Name:
Address:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
DC
WV
WI
WY
--
AB
BC
MB
NB
NF
NT
NS
ON
PI
PQ
SK
YT
GU
OU
PR
Zip:
Phone:
Fax:
Email:
Service Requested:
Please Choose Requested Services:
Use the control key to choose more than one:
Medical Management
Assigned to:
Additional Comments:
Claims Examiner:
Save My Information For Future Requests
(requires cookies to be turned on)
Same as last referral
First Name:
Last Name:
Company:
Address:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
DC
WV
WI
WY
--
AB
BC
MB
NB
NF
NT
NS
ON
PI
PQ
SK
YT
GU
OU
PR
Zip:
Phone:
Ext:
Fax:
Email:
Claim #:
If claim number is not relevant, enter: 0000
Your Internet Address:
18.97.14.82
Applicant's Attorney:
Same as last referral
First Name:
Last Name:
Firm Name:
Address:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
DC
WV
WI
WY
--
AB
BC
MB
NB
NF
NT
NS
ON
PI
PQ
SK
YT
GU
OU
PR
Zip:
Phone:
Fax:
Email:
Authorization obtained from applicants attorney?
Y
N
Not litigated
Physician:
First Name:
Last Name:
PH Degree:
Med Group:
Address:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
DC
WV
WI
WY
--
AB
BC
MB
NB
NF
NT
NS
ON
PI
PQ
SK
YT
GU
OU
PR
Zip:
Phone:
Fax:
Email:
Diagnosis:
Permanent and Stationary?
Y
N
Physician Within Network?
Y
N
Date:
Work Restrictions:
Case Details:
Telephonic
Full Field Assignment
One-Time Task Field Assignment
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