TOTAL
Care Management
Managed Care Referral Form
Line of Coverage
Select One
Workers' Compensation
Short Term Disability
Group Health
Auto Liability
General Liability
Date Submitted
Claimant
Last Name
First Name
Street Address
City
State
Zip
Telephone Number
Date of Birth
Social Security No.
Date of Injury/Ilness
Occupation
Wages
Date of Hire
Work Status
Select One
Returned to Work-Full Duty
Returned to Work-Light Duty
Out of Work
Terminated
Quit
Employer
Company Name
Street Address
City
State
Zip
Contact Person
Telephone Number
Attending Physician
Name
Street Address
City
State
Zip
Telephone
Attorney
Name
Street Address
City
State
Zip
Telephone
Referral Made By
Telephone