Referral Form

Please Fill Out This Form and Fax it to (815) 733-6946 and email it to healthconnectionil@sbcglobal.net

Along with any pertinent Medical Record or Information.

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CLAIMANT INFORMATION:

Claimant Name (required)

Claimant Address (required)

Claimant Phone (required)

Date OF Birth (required)

Fine/Claim Number (required)

Social Security Number

Date Of Referral

Date Of Injury

INJURY INFORMATION:

Nature Of Injury

Diagnosis

Treating Physician

Physician Address

Physician Phone

REFERRAL SOURCE INFORMATION:

Referred By (required)

Your Address (required)

Your Phone (required)

Your Fax

Your Email (required)

DOES THE CLAIMANT HAVE AN ATTORNEY: YesNo

Attorney Name

Attorney Address

Attorney Phone

Attorney Fax

PRE-INJURY INFORMATION:

Employers Name

Employer Address

Employer Phone

Employer Contact Person

Claimants Occupation

SERVICE REQUESTED:
Forensic Vocational TestimonyLabor Market SurveyMedical ManagementVocational Rehabilitation

ADDITIONAL NOTES: