Attending Provider's Referral Form

Attending Provider''s Referral Form - (Forms/Publications)
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Title Attending Provider''s Referral Form (108 KB DOC)

Attending Providers send this form to refer injured workers for medical opinion consultations, specialty/surgical consultations, concurrent care (authorization required), transfer of care consultation, or closing exam and impairment rating. Give a copy of the completed form to the injured worker.

Form number F252-098-000
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Keywords Consultation, obtain consultations, obtain or make referrals, referral, second opinion
Valid dates 10-2013
Contact information Managing Injured Workers' Claims
Claims for Job Injuries
Web pages For Medical Providers

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