For questions or to make referrals via email/phone, please contact us at
info@rehabwest.com
or
(760) 759-7500
Please Start Here:
Is this another submission for this Injured Employee?
No
Yes
Injured Employee:
*Please enter Claim # before uploading documents
Claim #
First Name
MI
Last Name
Address
City
State
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
Phone
Gender
M
F
SSN
Email
Injury Date
Birth Date
Working
TTD
Employer:
UR Dates:
Date of Referral Submission:
2/13/2025
Claim Administrator's Date of Receipt:
UR Type:
Prospective
Claims Requested / Advisory
Retrospective
Pharmacy Review
Concurrent
Appeal
IMRO Records
Claims Authorization
Accepted Body Part(s):
Same as last referral
Disputed Body Part(s):
Same as last referral
Treatment Requests for UR:
Treatment Requests Authorized by Claims (if any):
Would you like RehabWest to send a claims Authorization letter for these requests on your behalf?
Yes
No
Claims Examiner:
First Name
Last Name
Company
Address
City
State
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
Phone
Ext
Email
WCIS #
EAMS #
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
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
Phone
Fax
Email
Not Litigated
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
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
Phone
Fax
Email
Not Litigated
Requesting Physician:
First Name
Last Name
Address
City
State
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
Phone
Fax
Email
Additional Email Notification:
Email 1
Email 2
Email 3
Additional Instructions / Notes / Vendor Letter Instructions