For Physical Medicine services (PT, OT, FCE, Chiro, etc.) use the form below. Referrals can also be made via phone (888) 654-0049 or fax (205) 995-1894.
(Please note: the highlighted fields are required).
Submission Information
Claim Number:
Click here if billing address is same as company address.
Submitted By:
Email:
Last Name: Re-Enter Email:
Submitted By Company: Bill to Company:
Address 1: Address 1:
Address 2: Address 2:
City: City:
State: State:
Zip: Zip:
Phone:
Phone:
Unique Referral ID:
Is this a continuing authorization request?
Patient Information
First Name: Jurisdiction State:
Last Name:
Prescribed Services: Body Parts Injured:
Primary Phone:
Please make sure phone number is correct! 		Frequency & Duration:
Total Visits You Are Authorizing:
Special Instructions:
255 characters remaining
If you would like to fill in any additional information click here. Or, if you wish to submit the referral as is, click SUBMIT and we will take care of the rest.
You will also have the ability to upload related medical documents and notes after you click Submit.
Additional Patient Information
Secondary Phone:
Employer:
SSN:
 -  - 
Date of Injury:
 /  / 
mm/dd/yyyy
Address 1: Diagnosis Code:
Address 2:
City:
State:
Zip:
Date of Birth:
 /  / 
mm/dd/yyyy
Referring Physician Information
Physician's First Name:
Physician's Last Name: Phone:
Address 1: Fax:
Address 2:
City:
State:
Zip:
Case Management Information
Nurse Case Manager's First Name:
Nurse Case Manager's Last Name: Phone:
Email: Case Management Company Name:
(if applicable)
Adjuster Information
Adjuster's First Name: Email:
Adjuster's Last Name: Phone: