Referral Request

Complete the referral form below to process an appointment request with more than a 1 business day lead time. If less than 1 business day to your requested appointment, contact Optimal directly at 877-210-9011.

Service Type

Translation Transportation Both

Referral Profile

Type: Case Manager Adjuster Other
First Name
Last Name
Telephone	xxxxxxxxxx
Fax	xxxxxxxxxx
Email

Claimant Profile

First Name
Last Name
Last four digits of claimant's Social Security number XXX-XX-
Gender:	Male Female
Language	Other
Telephone	xxxxxxxxxx

Home Address

Street
Apartment #	Complex Name
City	State Zip

Work Address

Company
Street	Suite #
City	State Zip

Claim Details

Claim Number
Injury Occurred: Month Date Year
Injury Description

Attorney Information

First Name
Last Name
Telephone	xxxxxxxxxx Extension

Transportation

If transportation is required, where will the claimant be picked up? Home Work

Appointment

Requested Date of Appointment:
Month	Date Year
Time	: AM PM
Type (check all that apply):
Physician:	Initial Appt.	IME	Follow-up	Other
Facility:	Therapy	MRI	FCE	Other
Surgery:	Pre-op	Post-op	Entire Proc.	Other
Legal:	Deposition	Hearing	Mediation	Other

Location of Appointment

Appt. Name
Dept.
Contact
Telephone	xxxxxxxxxx Extension
Street	Suite #
City	State Zip

Additional Approved Locations

List additional approved locations below. If no additional locations, then leave blank.

Location
Address
Telephone	xxxxxxxxxx
Location
Address
Telephone	xxxxxxxxxx
Location
Address
Telephone	xxxxxxxxxx
Location
Address
Telephone	xxxxxxxxxx

Authorization

Authorization valid until:
Month	Date Year
By:	Referral Other
Authorization Number

Billing

Company
Attention:	Referral Other (list below)
First Name
Last Name
Title:	Case Manager Adjuster Other
Telephone	xxxxxxxxxx Extension
Fax
Street	Suite #
City	State Zip

Comments

Please list any comments, directions or additional instructions here.