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Referral Form

Referral Form

Download Printable Form

I'm interested in the following services:
Field Case Management			IME Set-Up
Task Assignment			Telephone Case Management
Vocational Rehabilitation			Job/Video Analysis
Ergonomic Assessment			Liability Review

I’m interested in the following IME Set-up services:
Provide IME physician choices			Schedule IME
Organize medical file			Send IME notice and travel expense to claimant
Obtain missing records			Provide customized, detailed  IME cover letter
Issue IME prepayment			Coordinate transportation to/from IME
Translation services			Attend IME
Secure IME report			Provide recommended plan for claimants deemed not MMI/FD
Medical Records UPLOAD FILES: (files must be < 2MB) Files over 2MB? Email us or Call us at 630-578-1120			Enter Captcha Above:

Home \| Services \| IME Set-up \| Meet Our Team \| Our Advantage \| Events & News \| Referral Form \| Contact Us
500 N. Randall Road, #266 Batavia, IL 60510P 630.578.1120 F 312.212.5892 info@customcasemanagement.com