Referral Form Please Fill Out This Form and Fax it to (815) 733-6946 and email it to hcofil@gmail.com Along with any pertinent Medical Record or Information. 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: