Refer a Patient to the MedRisk Network

Does your claimant require physical therapy, occupational therapy, or chiropractic care? Use our online form to refer your claimant to MedRisk! We’ll find your claimant the best provider at the most convenient location and schedule the Initial Evaluation for you!

Referred By:
* Name:
* Phone #:
Email address:

Patient Information:
* Name :
* Address:
* Home Phone:
* SS Number:
Date of Birth:
Injury/Employer
 Info:
* Date of Injury:
* Date of Surgery:
* Employer:
Work Phone:
Job Title:
Is patient working? Yes
Last day of work:
Work location:
Case Management (If applicable)
Rehab nurse name:
Company:
Phone:

W/C Insurance Info:
* Primary Insurance:
* Adjuster:
* Adjuster phone:
* Jurisdiction:
* Claim Open: Yes
* Claim Number:
* Authorization to treat: Yes
Authorization Code:
Type:
Group
 
Physician Info:
Referring MD:
Referring MD address:
Referring MD phone:
* Diagnosis:
Services:
 
Treating Therapy Provider Info  (If already treating:)
Provider:
Provider Location:
Date/Time of IE:

 

Imaging Specific Information (If applicable)
Procedure 1      Anatomy
Procedure 2      Anatomy
Procedure 3      Anatomy
Procedure 4      Anatomy

 

Send Reports to: Ref. Physician Case Manager Adjuster
Send Films to: Ref. Physician Case Manager Adjuster
 

Special Instructions


Items marked with (*) are required.

If you have any problems with this submission, please send an e-mail to:
medriskreferrals@medrisknet.com