PremierComp Solutions, LLC - Specializing in workers' compensation cost containment solutions.

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Referral type:
*Items in red are required
Refered by:
Name
Company
Phone
Email
Fax
Patient Information:
Name
Address 1
Address 2
City
State
ZIP
Dat of Birth
SS#
Phone
Cell
Work
Job Title

Employer
Address 1
Address 2
City
State
ZIP
Phone

Injury Information
Area of Body
Date of Injury

Diagnosis

Has the patient sought medical treatment
	Yes No
If yes where?
	ER Physician Other

Treating Physician
Address 1
Address 2
City
State
ZIP
Phone

Date of inital treatment

Followed up appointment information

Referred to a specialist
	Yes No
Referred for PT/Diagnostic Testing
	Yes No

W/C Insurance Billing Information:
Name
Address 1
Address 2
City
State
ZIP
Phone
Adjuster
Claim open:	Yes No
Claim number

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