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Referral: Workers Compensation

Step 1 of 6 - Referrer & Insurer Details

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  • Referrer's Details

  • Insurer's Details

  • Claimant's Details

  • Claimant's Work Details

  • Include the total number of hours that the employee is currently working.
  • As indicated on the certificate of capacity.
  • Claimant's Injury Details

  • Employer's Details

  • Treating Practitioner's Details

  • Services Required

  • Expected Outcomes and Comments

  • Approved Costs

  • Documentation

  • Drop files here or
    Max. file size: 50 MB.

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