Health Connection of Illinois14722 S. Naperville Rd, Suite 108 Plainfield Il 60544 Phone: 815.733.6940 Fax: 815-733-6946 Let’s Get Started Claimant Information Claimant Name First Name Last Name Claimant Address Address 1 Address 2 City State/Province Zip/Postal Code Country Claimant Phone (###) ### #### DOB MM DD YYYY File/Claim Number Social Security Number Email Date of Referral MM DD YYYY Date of Injury MM DD YYYY Injury Information Nature of Injury Diagnosis Treating Physcian First Name Last Name Physician Address Address 1 Address 2 City State/Province Zip/Postal Code Country Physician Phone (###) ### #### **IN ORDER TO PROVIDE AN ASSESSMENT, THE BELOW INFORMATION IS EXTREMELY PERTINENT. Please email FCE, IME, OPERATIVE REPORT & ANY REPORTS INDICATING RESTRICTIONS to both: Edward Pagella hcofil@gmail.com and Gina Harrison gharrison.hci@gmail.com Referral Source Information Name First Name Last Name Company Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Your Phone Number (###) ### #### Your Fax # (###) ### #### Your Email Address Representation Does the Claimant Have an Attorney? Yes No Attorney Name First Name Last Name Attorney Address Address 1 Address 2 City State/Province Zip/Postal Code Country Attorney Phone Number (###) ### #### Attorney Fax # (###) ### #### Insurance Company/Billing Information Bill To: Name/Company Claim Number Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number (###) ### #### Fax# (###) ### #### Pre-Injury Employment Information Employer Company Name Employer Address Address 1 Address 2 City State/Province Zip/Postal Code Country Employer Phone (###) ### #### Employer Contact Name First Name Last Name Claimant Occupation Please Indicate Service Request Forensic Vocational Testimony Labor Market Survey Medical Case Management Vocational Rehabilitation Other Additional Questions Thank you!