March 10, 2010 
Send a Referral: On-Line Referral Form
Referral Form
In a workers' compensation case, everyone shares the same goal- to help get the injured worker back on the job as quickly and effectively as possible. You know that The Work Center goes the extra mile to serve you and your client, employee, or patient. Our online referral form allows you- doctors, case managers, and employers, to refer workers to The Work Center with ease! Partnering with The Work Center is a great way to take a step towards getting your injured workers rehabilitated and back on the job. It's a small, simple step that will help you get the accurate, objective data you need to know.
Submit Form to:
Patient Information
Name:
Address:
 
Phone:
Email:
DOB: DOI:

Rehab Company Information
Name:
Address:
 
Phone:
Fax:
Email:
Case Mgr:

Physician Information
Name:
Address:
 
Phone:
Email:
Fax:
Contact:
Surgeries:
Diagnosis:
ICD-9 Code(s):
Services:
Services:
Restrictions:
Employer Information
Name:
Address:
 
Phone:
Email:
Contact:
Job Title:

Insurance Information
Name:
Address:
 
Phone:
Email:
Fax:
Claims Rep:
Claim #:

Services/Referral Question
Functional Capacity Evaluation
  RTW / VOC / MMI
1/2 Day Work Hardening/Cond
Full-Day Work Hardening/Cond
Work Hardening/Cond (other)
Physical/Occupational Therapy
Conditioning Program
MCU
Hanoun UE

Mike Frossard named Director o...
Sandy Huffman Named Program Ma...
Laura Hoagland joins The Work ...
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