SEND REFERRAL – MEDICAL CASE MANAGEMENT GROUP

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SEND A REFERRAL

Medical Case Management Group is accessible 24 / 7 / 365. However, if your referral is not an emergency, you may also contact us via one of the below means.

Do NOT Send Any Date of Birth(s) or Social Security Number(s)

To refer a case / referral to Medical Case Management Group:

Call us 24 / 7 / 365 at 1.800.730.4845 or email us or fill-out the form below:

Referral Date *

Referred by: *

First

Last

Please choose the type of referral you would like to submit:

Field Case Management
Telephonic Case Management
Vocational Rehabilitation
Labor Market Survey
Transferrable Skills Analysis
Independent Medical Exam
Task Assignment
Functional Capacity Evaluation
Physician File Review
Nurse File Review
Pharmacy Review
Other Services (i.e. Ergonomic Evaluation, Job Analysis, Medical Cost Projection, etc)

*Please note, if you have chosen 'Other,' please specify in the comments section below.

Claimant Information:

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Date of Birth *

DOI *

Diagnosis *

Attorney Information (if applicable)

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Fax

Insurance Company Information

Name *

Adjuster Name *

First

Last

File Number

Phone *

Fax

Employer Information

Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Fax

Contact Person *

First

Last

Please address the following:

Diagnosis
Reasonableness of Fees
Prior History
Current Medical Status
Work Status
Prognosis
Causal Relationship
Maximum Medical Improvement (MMI)
Treatment/Diagnostitcs Recommended
Length of Total/Partial Disability
Permanency Expected
Permanent Impairment Rating (PI Rating)

Special Instructions:

Rush
WIll Forward Further Medicals
Review Attached Films

Additional Information

Want to connect or need more information?

Call us: (888) GET-MCMG or contact us via the form below:

Name *

Phone *

Email *

Medical Case Management Group

PO Box 938 Gray, Maine 04039

Phone: 888-GET-MCMG / 888-438-6264 | Fax: 207-892-1531 | Email: [email protected]

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