Fax to Rehabilitation Specialists Group, Inc.
602-336-4734

Person Requesting Service Affiliation Date
Address Telephone No.
Type of Insurance Claim No. Attorney Name (if applicable)

REFERRAL INFORMATION

Client Name (last, first) Date of Injury Social Security No.
Address Date of Birth Telephone No.
Employer/Insured Address Telephone No.
Diagnosis (if available)

Physician Address Telephone No.
Hospital Address Telephone No.

TYPE OF SERVICE REQUESTED

ckbox.gif (857 bytes)  Case Management
ckbox.gif (857 bytes)  Telephonic Case Management
ckbox.gif (857 bytes)  One-Time Case Management Assessment
ckbox.gif (857 bytes)  24-Hour Injury Reporting
ckbox.gif (857 bytes)  Life Care Planning
ckbox.gif (857 bytes)  Medical Liability
ckbox.gif (857 bytes)  Independent Medical Evaluation (IME)
ckbox.gif (857 bytes)  Medical Bill Audit
ckbox.gif (857 bytes)  Medical Records Review
ckbox.gif (857 bytes)  Vocational Evaluation
      (specify moderate or comprehensive
ckbox.gif (857 bytes)  Vocational Counseling/Plan Development
ckbox.gif (857 bytes)  Job Placement
ckbox.gif (857 bytes)  Labor Market Survey
ckbox.gif (857 bytes)  Job Analysis
ckbox.gif (857 bytes)  On-Site Ergonomic Assessment
ckbox.gif (857 bytes)  Expert Legal Testimony
ckbox.gif (857 bytes)  Other (please specify in Special Instructions)
SPECIAL INSTRUCTIONS