Medical Expense Management Inc.
Worker's Compensation Referral form
*Note: All fields are required
Insurance Company Information (if known)
Name:
Name:
Claim #:
Employee Information
Name*:
Gender:
Address:
City:
State
Zip Code
Phone:
DOB (xx/xx/xxxx):
SSN:
Jurisdiction of WC Claim:
Title:
Medicare Beneficiary:
Name as it appears
on Medicare Card:
Medicare Number (HICN#):
Social Security Disability Beneficiary:
Account Information (Billing)*
Account Name:
Adjuster*:
Address:
City:
State
State
Phone*:
Email*:
Fax:
Claim Number:
Notes:
Employer Information
Account Name:
Name:
Address:
City:
State:
Zip:
Contact:
Title:
Phone:
Email:
Employee's Attorney
Name:
Address:
City:
State:
Zip:
Phone:
Email:
May MedAllocators contact this person directly?
Defense Attorney
Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
May we contact this person directly?
Additional Notes: