Pandemic Management Program - COVID 19

YOU'RE MAKING A REFERRAL FOR
The Reny Company's Pandemic Program - COVID 19

Use this form when you want to make a referral for a COVID-19 related case. Please fill out the form with as much case information as possible and submit online. If you'd prefer, you can talk to our referral team directly: (800) 880-6201.

Claim Professional

Nurse Case Manager

Treating Physician

Date of injury *

Date of injury reported to you

Hospital / Facility

Home

Other

Hospital / Facility name

Is the injured worker in an ICU setting?

Yes

No

Contact Name

Address

Email

Phone

Fax

Name

Company

Company type

Insurance Carrier

Employer

TPA

Other

Address

Email

Phone

Fax

Are you the primary case contact?

Yes

No

Company name

Name

File/Claim number

SSN or worker ID

Address

Gender

Female

Male

Unspecified

Phone

Date of birth

Primary language

Occupation

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