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Request for Provider Panel
Patient Name
Home Address
City
State
ZIP
SS Number
Home Phone
Work Phone
Cell Phone
Fax Number
Claim No. (If Available)
Date of Injury
  /     /    
Date of Birth
  /     /    
Occupation
Type of Injury (If Available)
Did patient go to ER or seek medical treatment yet?
 
If yes: where?
Employer Name
Caller Name
Employer Contact
Phone Number
Insurance Carrier
Appointment Information
Special Instructions /
Misc. Information


    

Sharon Kress
Director, Injury Management
(412) 494-4001

 

Home | Contact | Links | Request Provider Panel Services | Make a Referral
Provider Panels | Injury Management | PT Network | Diagnostic Network
Pharmacy Network | Repricing & Medical Bill Review
Physician Medication Dispensing Services | Power Point Presentation

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