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Case Management
Referral
Contact Us
Fill in the information as it applies to your type of claim. Fax a copy of the Form 19 and the 25N to (910) 429-0085 in NC worker's compensation cases.
Referral Contact Information
First Name:
MI:
Last Name:
Email:
Type of Claim
Worker's Compensation
General Health
General Liability
Type's of Service
Field Based Case Management
Telephonic Case Management
Medical Record Review
Account Information
Account Name:
Address:
Address:
City:
State:
Zip:
Adjuster Name
First Name:
Last Name:
Adjuster No:
Phone:
Ext:
Fax:
Email:
Claimant
Prefix:
First Name:
MI:
Last Name:
Address:
Address:
City:
State:
Zip:
Phone:
DOB:
DOI:
Occupation:
Dx:
Treating Physician:
Attorney
Name:
Address:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Claim Information
State of Claim:
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Dist. of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Claim Number:
Bill to Information
Same as Account Information?
Yes
No
Name:
Address:
Address:
City:
State:
Zip:
Phone:
Ext:
Fax:
Employer Information
Name:
Address:
Address:
City:
State:
Zip:
Contact Name:
Phone:
Ext:
Fax:
Email:
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