Catastrophic Care Management

YOU'RE MAKING A REFERRAL FOR
Catastrophic Care Management

Use this form when you need comprehensive care management for a challenging and expensive catastrophic injury: acute brain injury, spinal cord injury, severe burns, amputations, or multiple trauma.
If this doesn't sound like your case, you can go back and choose a different referral type.

Claim Professional

Nurse Case Manager

Treating Physician

Name

Company

Company type

Insurance Carrier

Employer

TPA

Other

Address

Email

Phone

Fax

Are you the primary case contact?

Yes

No

Name

File/Claim number

SSN or worker ID

Address

Gender

Female

Male

Unspecified

Phone

Date of birth

Primary language

Occupation

Hospital / Facility

Home

Other

Date of injury *

Date of injury reported to you

Hospital / Facility name

Contact Name

Address

Email

Phone

Fax

Company name

Contact Name

Address

Email

Phone

Fax

Firm name

Attorney name

Address

Email

Phone

Fax

Physician name

Address

Email

Phone

Fax

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