Cur IW:{none selected}
 
Make a referral your own way.
1. Request a blank form to complete and FAX or Email back.
2. Make a Telephonic Referral at 800-890-1620
3. Complete & Submit an Online Referral Form below.

The referral process will begin with a telephonic consultation to review specific goals, time lines and special service instructions. Please plan to spend at least 5-10 minutes with your account manager at the onset of each referral.
COMPLETE eREFERRAL NOW!

Referral Client Information
Company Name
Adjuster Name
Address Line 1
Address Line 2
City
State
Zip Code
Daytime Phone
Fax
E-mail Address
Private Label Case? No Yes
Employer Company:
Employer Contact
Employer Phone
Employer Email
Injured Worker Information
Referral Type New Referral
Reopen
Claim #
Jurisdiction
Date of Loss
IW First Name
IW Last Name
IW Address
IW City
IW State
IW Zip_Code
IW Phone
IW Email
Gender
Date of Birth
Physician
Injury
Impacted Body part(s)
Covid Vaccination Status:
Next Doctor's Appointment Date:
Restrictions
Prior Work Exp
AWW $
LD Wage / Hr $
Language Barrier? No Yes
Language Notes:
Case Manager
Services Requested
Comments

Attached Injury History
Note: To include multiple attachments, or for files greater than 15MB, please send document(s) as an email attachment to referral@workbridgelink