Case Management - Arkansas and Louisiana



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Request for Service

Welcome to our online referral form. Required fields are marked with an asterisk (*). Use the tab key to move from field to field. Do not press Submit until the form is completed.

Referral Requested By

First Name	*
Last Name	*
Company	*
Address	*
City	*
State	*
Zip	*
Phone
Fax
Email	*

Claimant Information

First Name	*
Last Name	*
Address	*
City	*
State	*
Zip	*
Phone	*
Alt. Phone
Date of Birth

Claim Information

Claim #	*
Date of Loss	*
Diagnosis

Type of Claim

PIP
Liability
Workers Comp
Other
State

Service Requested

                     
                    Appeal 
                     Physician's
                    Name to Respond to Appeal

Audit

Provider
DOS

Bill Repricing

Code Review

PreCertification

Radiological Review

Cervical

Lumbar

Other

IME

Specialty

Peer Review

Specialty
Provider
DOS

                     
                      (PRO) Peer
                    Review

Case Management

Medical Case Management

One Time Assessment

Cost Projection

Telephonic Case Management

Provider Information

Name
Specialty
Phone

Attorney Information

Name
Specialty
Phone

Additional Comments and Special Requests

Please Enter the Current
Date and Time

After the referral is submitted, a confirmation page will be displayed. Print a copy for your records.

Toll Free: 866-532-1929
Phone: 985-845-4548
Fax: 985-845-9913

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