Request a Referral

Thank you for your business. Please take a moment and complete this form, including the service you are requesting. A Care^IQ representative will begin the scheduling process immediately.

Service(s)
	Please select referring service.
	Radiology Service (includes MRI, CT, EMG, Bone Scan, etc.)
	Peer Review
	Independent Medical Exam (IME)
	Durable Medical Equipment (DME)
	Transportation
	Translation Services
	Physical Therapy
	Age of Injury
	Second Opinion
Contact Information
	First Name*
	Last Name*
	Email Address*
Patient/Claimant Information
	Patient Name
	Address
	Address 2
	City
	State	Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin
	Zip
	Home Phone
	Work Phone
	Other Phone
	Social Sec Number
	Date of Birth	/ /
	Sex	MF
	Date of Injury	/ /
	Employer
	Employer Phone
	Pefer Language	English Spanish Other
	Other Language
	Stat	Yes
	Claim Type	Workers' Comp Auto Group Health
	Comments
Adjuster/Case Manager Information
	Adjuster Name
	Company Name
	Phone
	Fax
	Insurance Co. Name
	Billing Address
	Billing Address 2
	City
	State	Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin
	Zip
	Adjuster Email
	Auth #
	Case Manager Name
	CM Company
	CM Phone
	CM Email
	CM Fax
	Claim Number
	Report to Case Mgr	YesNo
Physician Information
	Referring Physician
	Physician Phone
	Physician Fax
	Records Address
	Records Address 2
	City
	State	Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin
	Zip
	Contact
	Contact Phone #
	Films Required?	YesNo
	Patient to carry film?	YesNo
Procedure 1 Information
	Diagnosis
	Other Diagnosis
	Procedure
	Scanned Area
	Age of Injury?
	Comments
Procedure 2 Information
	Diagnosis
	Other Diagnosis
	Procedure
	Scanned Area
	Age of Injury?
	Comments
Procedure 3 Information
	Diagnosis
	Other Diagnosis
	Procedure
	Scanned Area
	Age of Injury?
	Comments